child form 1 - eccdcouncil.gov.ph Checklist Child s... · checklist. Some of the questions are for children older than your child so I do not expect him to be able to do all the things

Early Childhood Care and Development (ECCD) Checklist, Child’s Record 1 1

Child’s Name: Sex: Date of Birth:

Address:

Child’s Handedness (Check appropriate Box) right left

both not yet established

Is the child presently studying? (Check appropriate Box) Yes No

If Yes, write name of child’s school / learning center / day care:

Father’s Name: Fathers Age:

Father’s Occupation: Father’s Educational Attainment:

Mother’s Name: Mother’s Age:

Mother’s Occupation: Mother’s Educational Attainment:

Child’s Number of Siblings Child’s Birth Order (1st, 2nd, 3rd, etc.):

(Brother/s and Sister/s):

Sociodemographic ProfileIndicate the complete sociodemographic profile of the child.

Barangay Municipality/City Province Region

month day year

Early Childhood Care and Development (ECCD) Checklist, Child’s Record 12

Introduce the Checklist to the parent/caregiver by saying the following:

We are here to help you find out how your child is developing by asking you some questions about thethings he is able to do or having your child do some activities. There is no pass or fail score. This is just achecklist. Some of the questions are for children older than your child so I do not expect him to be able todo all the things I will be asking.

We plan to administer this Checklist several times until your child is 6 years old. So please do not teachor coach him because it is important to know just what he can and cannot do at this age.

Later on we will share the results with you and give suggestions on what else you can do to stimulate yourchild’s development.

After rapport has been established, introduce the Checklist to the child aged 1.0 year or older by saying the following:

I will be asking you to do some things for me today. Some of them will be very easy. Some of them may bea little hard for you. Do not worry if you cannot do them all because some of the activities are for childrenwho are a little older than you. So I do not expect you to be able to do everything I ask. Just try your best.

Date TestedChild’s Date of BirthChild’s AgeDate TestedChild’s Date of BirthChild’s AgeDate TestedChild’s Date of BirthChild’s AgeDate TestedChild’s Date of BirthChild’s AgeDate TestedChild’s Date of BirthChild’s AgeDate TestedChild’s Date of BirthChild’s Age

Year Month Day Examiner’s Name

5-8months

0-4months

13-18months

9-12months

19-24months

25-36months

AssessmentNo.

Introducing the Checklist

Computation of the Child’s AgeAfter verifying the dates, compute the child’s age by subtracting his birthday from the date the test is administered. Assume thateach month is composed of 30 days. Therefore, do not round off the months or years. Write the examiner’s name each time thetest is administered.

It is recommended that the Checklist be administered to the child at six intervals.Once every four months from ages 0 to 12 months; and once every six months fromages 13 to 36 months (1 year 1 month to 3.0 years).


This form can be used for six separate evaluations of the same child so it will be easy for you to seehow he is developing as he grows older. The “Present” portion of this Form has 6 columns where youare to mark the child’s skills and behavior each time you assess him. If the child exhibits the skill orbehavior, put a check ( ) in the designated column. If the child does not, put a hyphen (-) andwrite additional information in the “Comments” column explaining why.

Where to start and stop

For infants aged 0 month to 1.0 year:

The first few items in each domain pertains to infants or children from 0 to 1.0 year. These are thosein the “Infants Section.” Administer all these items. Then continue administering the rest of theitems in the domain, including those in the Section labeled “Optional starting point for children aged1 year and 1 month to 3.0 years” .

Stop only after five consecutive items in each domain have been marked with a hyphen (-).

For children aged 1 year 1 month to 3.0 years:

You may start with the section labeled “Optional starting point for children aged 1 year and 1 monthto 3.0 years” if the child is 1 year and 1 month old or older and you observe that he is able to do allthe items enumerated in the “Infants Section.” But if he is not yet able to do the Infant items, thenalways start with Item # 1 of each domain.

Administer all the items in this “Optional” section.

How to score

Tally the number of check marks ( ) in each domain and record this in the section labeled“Total Score.” If you choose to skip the Infants Section, you still have to place a check onthe items in that section. They are to be counted when you add up the scores for eachdomain.

How to Administer


Gross Motor DomainA. Infants Section (Ages 0 month - 1.0 year)

Gross Motor Material/Procedure

1.

2.

3.

4.

5.

6.

7.

1st 2nd 3rd

Present Comments4th 5th 6th

PROCEDURE:Hold the child in an upright position andcarefully remove your hand from the child’sneck according to his ability to lift his headand keep it erect. Credit if the childoccasionally lifts his head free of support.Parental report will suffice.

PROCEDURE:Place the child on his stomach on a flatsurface. Credit if the child at leastmomentarily lifts his head so that the chinis off the surface. Parental report willsuffice.

PROCEDURE:Place the child on his stomach on a flatsurface. Credit if the child lifts his headand chest up so that his face makes a 90°angle w/ the surface for at least severalseconds. Parental report will suffice.

Parental report will suffice.

PROCEDURE:Place the child on his back on a flat surface.Encourage him to roll over to his stomach,providing some assistance to do so. Creditif he eventually rolls over. Parentalreport will suffice.

PROCEDURE:Roll the child from his back to his side.Make sure he is not restricted by his clothesand his arm is not caught under his torso.Credit if the child actively turns from hisside to his back. Parental report willsuffice.

PROCEDURE:Hold the child in a sitting position on thetable and slowly remove your hand from thechild making sure that he does not fall.Credit if the child sits alone and puts hishands on his legs or on the table forsupport. Parental report will suffice.

Infant lifts headwhen held standing

Infant tries to lifthead when lying onstomach

Infant holds headupright on his ownwhen lying onstomach

Infant holds headsteadily

Infant rolls over fromhis back to hisstomach withassistance

Infant turns from hisside to his backwithout assistance

Infant sits well withsupport, leaning onhands if placed onhard surface


Gross Motor Material/Procedure1st 2nd 3rd


8.

9.

10.

11.

12.


PROCEDURE:Hold the child in a sitting position on thetable and slowly remove your hand from himmaking sure that he does not fall. Credit ifthe child sits alone steadily withoutsupport, keeping his back fairly straight.Parental report will suffice.

MATERIAL: any toyPROCEDURE:Seat the child on the floor. Place a toy onthe floor, in front of the child, but notwithin his reach. Observe how the childmoves from sitting to creeping positionand the type of movement he makes toreach for the toy. Credit if the childmoves forward about 9 inches or more,using either of the following: hands andknees, stomach and arms, hands andfeet. Parental report will suffice.

PROCEDURE:With the child in a sitting position, holdboth his hands and have him pull himselfup with only minimal assistance from theadult. Credit if the child can stand up.Parental report will suffice.

MATERIAL: elevated piece of furniturePROCEDURE:Credit if the child holds on to a piece offurniture with both hands and bears weighton both feet. Parental report willsuffice.

Infant bounceswhen held standing,briefly bearingweight on legs

Infant sits alonesteadily

Infant moves fromsitting to creeping/crawling position

Infant pulls selffrom sitting tostanding positionwith minimalassistance

Stands withminimum support


B. Optional starting point for children aged 1 year 1 month - 3.0 years



13.

14.

15.

16.

17.

18.

19.

MATERIAL: toyPROCEDURE:While the child is standing, observe if hemoves from one point to another bywalking sideways. He may support himselfby holding on to furniture. He can beencouraged to walk by placing a toy onthe furniture near the child but justoutside his reach so he must walk toreach the toy. Credit if the child walkssideways while holding on to furniturefor support and balance. Parentalreport will suffice.

PROCEDURE:Observe the child if he walks when bothhands are held by an adult. Credit if thechild takes coordinated walking stepswith only slight support from the adult.Parental report will suffice.


PROCEDURE:Observe the child if he walks alone acrossthe room. Credit if the child walksalone with good balance withouttripping and rarely falling. Parentalreport will suffice.

PROCEDURE:Ask the child to walk backwards bydemonstrating it. Credit if the child isable to walk backwards without fallingand holding on to anything. Parentalreport will suffice.

MATERIAL: ballPROCEDURE:Encourage the child to run by rolling aball across the floor. Credit if the childcan run fast and smoothly withouttripping or falling.


Holds furniture withboth hands andwalks sideways

Walks with bothhands held

Climbs on chair oranother elevatedpiece of furniturelike a bed withouthelp

Walks alone, rarelyfalls

Walks backwards

Runs withouttripping or falling

Walks down stairs, 2feet on each step,with one hand held




20.

21.

22.

MATERIAL: toyPROCEDURE:Place a toy in the middle of the step andask the child to walk up the stairs to getthe toy. Credit if the child walks up thestairs using the handrail or wall forsupport and places both feet on eachstep before stepping on the next one.Parental report will suffice.

MATERIAL: toyPROCEDURE:Place a toy in the middle of the step andask the child to walk upstairs to get the toy.Credit if the child walks upstairs,alternating his feet as he steps on eachsuccessive step without holding on tothe handrail or wall for support.Parental report will suffice.

MATERIAL: toyPROCEDURE:Place a toy at the bottom of the stairs andask the child to walk downstairs to get thetoy. Credit if the child walks downstairs,alternating his feet as he steps on eachsuccessive step without holding on tothe handrail or wall for support. Do notgive credit if the child places both feeton the step or uses the handrail or wallfor support.Parental report will suffice.

TOTAL SCORE

Walks up stairsholding handrail, 2feet on each step

Walks upstairs withalternate feetwithout holding onto the handrail

Walks downstairswith alternate feetwithout holdingonto a handrail


Fine Motor Material/Procedure1st 2nd 3rd


1.

2.

3.

4.

Fine Motor Domain

PROCEDURE:Observe the infant’s hands. Credit if hishands are open most of the time.Parental report will suffice.

MATERIAL: dangling object/toyThis must be elicited by theinterviewer.PROCEDURE: Dangle the toy in front ofthe child

MATERIAL: dangling object/toyThis must be elicited by theinterviewer.

MATERIALS: small toy/spoonPROCEDURE:Hold a small toy/spoon in your hand andurge the infant to get it.This must be elicited by theinterviewer.

A. Infants Section (Ages 0 month - 1.0 year)

Hands of infant arekept open most ofthe time

Infant waves arms,moves body at thesight of a danglingobject/toy

Infant brings bothhands togethertoward danglingobject/toy

Infant reaches forand holds small toy/spoon

B. Optional starting point for children aged 1year 1 month - 3.0 years



5.

6.

7.

Uses all five fingers toget food/toys placedon flat surface

Picks up objects withthumb and indexfinger

Pulls toy with string

MATERIAL: any small toy /objectPROCEDURE:Seat the child on the parent’s lap with hiselbows at level with the tabletop and hishands on the table or flat surface. Drop asmall toy in front of him and attract hisattention by pointing to the toy or tappingthe table/flat surface. Credit if the childpicks up the toy, using all five fingersas if raking.

MATERIAL: any small toy or foodPROCEDURE:Place a toy/food in front of the child andwithin his reach. Attract his attention bytapping near the toy/food. Credit if thechild uses the pads of his thumb andindex or forefinger to pick up the toy/food.

MATERIAL: toy with stringThis must be elicited by theinterviewer.




8.

9.

10.

11.

12.

13.

14.

MATERIAL: toyPROCEDURE:Place the toy directly in front of the child atmidline (not to his left or his right) andask him to reach for this. Credit if heuses the same hand two out of threetimes. Parental report will suffice.

MATERIALS: 2 small toysPROCEDURE:Observe if the child transfers a small toyfrom one hand to the other. Encourage thisby giving the child a toy and then present-ing another toy to the same hand. Credit ifthe child transfers a toy from one handto the other without using his mouth orbody.

MATERIAL: Interviewer’s kit or some largeobjectPROCEDURE:Demonstrate pushing or pulling a largeobject.This must be elicited by the inter-viewer.

MATERIALS: small objects and containerThis must be elicited by theinterviewer.

MATERIAL: crayonPROCEDURE:Present child with a crayon and have himget this. Credit if he holds it by wrappingall five fingers around as if making a fist.Automatically Credit this item if he uses thetips of all five fingers or the tips of histhumb, index, and middle fingers.This must be elicited by theinterviewer.

MATERIALS: Container with screw-on topor wrapped candy.This must be elicited by theinterviewer.

MATERIALS: paper, pencil/crayonPROCEDURE:Place a paper and pencil/crayon on thetable and ask the child to draw anything hewants without showing him what to do.Credit if the child uses the tips of histhumb and any of his other fingertips tograsp the pencil/crayon and makespurposeful scribbling marks on thepaper (not accidental marks).

TOTAL SCORE

Displays a definitehand preference

Grasps and transfersobjects from handto hand

Pushes or pulls alarge object

Puts small objectsin/out of container

Holds crayon withall the fingers of hishand making a fist(i.e., palmar grasp)

Unscrews lid ofcontainer orunwraps food

Scribblesspontaneously


Holds bottle all byhimself

Feeds self withfinger food (e.g.,biscuits, bread)using fingers

Helps hold a cupfor drinking

Feeds self usingfingers to eat rice/viands with spillage

Drinks from a cupwithout help

Feeds self using aspoon with spillage

Gets a drink forhimself without anyhelp


MATERIALS: bread, biscuitsThis must be elicited by theinterviewer.

Note: The cup should not have a lid orspout.


MATERIALS: drinking cup, waterThis must be elicited by theinterviewer.



TOTAL SCORE

Infant sucks andswallows milk frombreast or bottle

Infant begins to takesolid foods

Chews solid foodwell


Ask the caregiver if the child can takesemi-solid or mashed foods. Credit if thecaregiver reports that the child toleratesthese. Write “No opportunity” in thecomment section if the child has notbeen introduced to solid foods.


Self-Help Material/Procedure1st 2nd 3rd


1.

2.

3.

Self-Help DomainA. Infants Section (Ages 0 month - 1.0 year)


Self-Help Material/Procedure1st 2nd 3rd


4.

5.

6.

7.

8.

9.

10.


Material/Procedure

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2.

3.

4.

5.

6.

7.

8.

9.

1st 2nd 3rd


Receptive Language DomainA. Infants Section (Ages 0 month - 1.0 year)

Infant startles toloud sounds

Infant turns eyes/head toward sound

Infant watchesmother intently asshe speaks to him

Infant smiles at afamiliar voice, likewhen his mothertalks to him.

Infant stops cryingwhen sung to

Turns head whencalled by name,makes eye contact

Understands “no”

Imitates adults’playful sounds likecoughing, lipsmacking

Follows one step-command (e.g. give)when gestures areused


MATERIAL: rattlePROCEDURE:Carry the child on his back with one handand with the other shake a rattle out of hisrange of vision 6 inches from his ear. Dothis continuously for 3 seconds andobserve whether he can turn towards thesound. Credit if the child widens ormoves his eyes from side to side insearch of the sound.




PROCEDURE: Go behind the child a fewfeet away and call out his name. Observe ifthe child can look for you and smile.Parental report will suffice.

PROCEDURE: Shake your head and fingerand say “No-no”. Then see whether thechild understands this. Credit if the childstops what he is doing. Parentalreport will suffice.

PROCEDURE: Place the child on thecaregiver’s lap with you facing the child.Then make the following sounds: cough,smack lips. Credit if the child makes thesame sound or even just the lipmovements.

MATERIAL: spoon or any objectPROCEDURE:With the child seated in front of you, givehim a spoon then ask for the spoon backby saying “GIVE ME THE _(object)__.”with your hand (palm up) toward him.Credit if the child looks at the objectand hands it over to you even if hedoes not release this immediately.

Receptive Language


Follows one step-command withoutneed for gestures

Points to a familymember whenasked to do so

Material/Procedure1st 2nd 3rd


10.

11.

Points to five bodyparts on himselfwhen asked to doso

Points to fivenamed picturedobjects when askedto do so

Follows one-stepinstructions thatinclude simpleprepositions (e.g.,in, on, under, etc.)

Follows two-stepinstructions thatinclude simpleprepositions

B. Optional starting point for children aged 1year 1 month - 3.0years

PROCEDURE:Have the child point to his eyes, nose,mouth, hands and feet. Credit if he canpoint to all these.

MATERIAL: picture book 1PROCEDURE:Show the child a picture book (twopictures per page) and ask him to point tothe picture by saying “Where’s the______?” Credit if the child can usehis finger to point to at least fivepictures.

MATERIAL: block/toyPROCEDURE:Ask the child to put a block/toy under thetable; on the table; in the bag. Do notpoint or use gestures when giving theinstruction. Credit if the child is able tofollow at least one of the instructions.

MATERIAL: block/toyPROCEDURE:Ask the child to get a block/toy fromunder the table and then place it on thetable. Do not point or use gestures whengiving the instruction. Credit if the childis able to follow.

TOTAL SCORE

Receptive Language Material/Procedure1st 2nd 3rd


12.

13.

14.

15.

MATERIAL: toyPROCEDURE:Place the toy on the floor and ask thechild to pick this up without pointing tothe toy or using any other gesture. Creditif the child picks up the toy.

PROCEDURE:Ask the child to point to his mother/caregiver. Credit if he does so.

Receptive Language


Expressive Language Material/Procedure

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4.

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7.

8.

9.

10.

11.

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1st 2nd 3rd


Expressive Language Domain

A. Infants Section (Ages 0 month - 1.0 year)

Infant vocalizes (e.g.,gurgles, coos, grunts)

Infant vocalizes to expresspleasure or displeasure

Infant shouts to attractthe attention of thecaregiver

Infant laughs out loudand squeals

Infant vocalizes differentvowel sounds (e.g., ahh,oooh)

Infant vocalizes othersounds that do not meananything

Infant babblescontinuously to amuseself or attract attention

Infant tries to imitate thecaregiver’s vocalizations

Infant uses bodymovements/gestures tomake wants known (e.g.,stretches arms to indicatewhat he wants)

Repeats vowel-consonant combinationswithout referring toanything or anyone (e.g.,baba, mama, dada)

Uses sounds meaningfullyto refer to specificobjects/persons (e.g.“Mama” for his mother;“mamam” for water)






PROCEDURE:Ask caregiver if the child can maketwo different sounds apart fromcrying like “goo”and “er”. Takenote of the sounds. Parentalreport will suffice.






Expressive Language Material/Procedure Present CommentsB. Optional starting point for children aged 1 year 1month - 3.0 years





PROCEDURE: Ask the caregiver if thechild can clearly say five to six wordsaside from mama and papa. This willbe the minimum number.



MATERIAL: picture bookPROCEDURE: Show the child apicture book, point to an object inthe book, then ask him to name this(e.g., Ano ito?). Credit if the childcan say the correct name of atleast four objects. Parentalreport will suffice.




PROCEDURE: Ask the caregiver if the child canrecount recent experiences in correctsequence and using past tensescorrectly. The caregiver can prompthim so he can complete what he istalking about (e.g., Tapos ano pangnangyari?). Parental report willsuffice.

Expressive Language Material/Procedure1st 2nd 3rd


13.

14.

15.

16.

17.

18.

19.

20.

21.

22.

Tries to imitate realwords of adult

Combines single wordsand gestures to makewants known (e.g., “out”while pointing to thedoor)

Uses 5 to 20recognizable words

Uses pronouns (e.g. I,me, ako, akin)

Uses two- to three-wordverb-noun combinations(e.g., hingi gatas)

Names objects inpictures

Speaks in grammaticallycorrect two- to three-word sentences

Asks “what” questions

Asks “who” and “why “questions

Gives account of recentexperiences (withprompting) in order ofoccurrence using pasttense

Chatters in aconversational tonewithout using real words.

12.

TOTAL SCORE


Cognitive Material/Procedure

1.

2.

3.

4.

5.

6.

7.

8.

1st 2nd 3rd


Cognitive DomainA. Infants Section (Ages 0 month - 1.0 year)

Infant inspectssurroundings

Infant gazes slowly atmoving objects/people

Infant turns head tobright coloredobjects

Infant changes facewhen he does notlike the taste of hisfood

Infant explores andmanipulates objectsby biting, holding,and looking at them

Infant shakes toydeliberately to makethis sound

Infant eventually getsused to irritating orbothersomeenvironmentalsounds (e.g.,tricycle, crowing ofcock)

Infant reacts to clothplaced over his face

Credit if the infant looks around theroom.




MATERIAL: clean toy/objectPROCEDURE:Give the child a clean toy or object andobserve if he brings it to his mouth to biteor chew.

MATERIAL: rattlePROCEDURE:Give the child a rattle and observe if hecan make it sound. Credit if the childcan hold a rattle and shake it for a fewseconds, hit it on the mat or wave it.

PROCEDURE:Ask the caregiver if the child eventuallygets used to environmental sounds likethat of a tricycle/other vehicles, sound ofanimals (chicken, dogs) that may havewoken, bothered or irritated him earlier.Parental report will suffice.

MATERIAL: cloth (handkerchief or facetowel)PROCEDURE:With the child lying on his back, gentlycover his face with a paper/cloth andobserve if he tries to remove this or pull itaway.


Cognitive Material/Procedure

9.

10.

11.

12.

13.

14.

15.

16.

1st 2nd 3rd



Looks in thedirection of a fallenobject

Displays a preferencefor certain objects byreaching for thesemore readily thanothers

Pushes the ball tomake it roll

Repeatedly drops orthrows objects

Looks for a partiallyhidden object

Imitates behaviorseen just a fewminutes earlier

Offers object but willnot release it

Looks for completelyhidden object

MATERIAL: spoon/ballPROCEDURE:With the child seated, get his attention anddrop a spoon/ball in front of him. Thenobserve if his eyes look down as the objectfalls. Credit if the child can bring his eyesand head down as the object falls.


MATERIAL: ballThis must be elicited by theinterviewer.

MATERIAL: toyPROCEDURE:While carrying the child, hand him the toyand see if he drops or throws this as iffascinated with the act of doing so.Parental report will suffice.

MATERIALS: ball, small towel/clothPROCEDURE:With the child facing you, partially hide aball behind a small towel and observe if hewill look for it and find it. Credit if thechild pulls the towel and gets the hiddenball.



MATERIALS: ball, small towel/clothPROCEDURE:With the child facing you, hide a ballcompletely under a small towel and observeif he will look under the towel. Credit if helooks under the towel and gets the hiddenball.


17.

18.

Exhibits simplepretend play (feeds,puts doll to sleep)

Matches objects

MATERIALS: doll or toy car/blockPROCEDURE:If the child is a girl, carry the doll and try torock it to sleep. If the child is a boy, movethe toy car/block back and forth. Credit ifthe child can imitate this.

MATERIALS: pairs of spoons, balls, blocksPROCEDURE:Place one spoon, one ball, and one blockon the table. Give the child the other set ofobjects arranged in random order.Demonstrate a matching response (e.g.,spoon to spoon) then return the objects tothe child. Say, “Put each object on the onethat is just like it.” Credit if the child canmatch the objects correctly.

TOTAL SCORE

Cognitive Material/Procedure1st 2nd 3rd




Social-Emotional Material/Procedure

1.

2.

3.

4.

1st 2nd 3rd


A. Infants Section (Age 0 months - 1.0 years)

Social-Emotional Domain

Infant stops cryingwhen mother pickshim

Infant smiles inresponse to thecaregiver

Infant reacts tofamiliar situationslike bathing orfeeding (e.g.,thrashes about, sucksvigorously at the sightof bottle)

Infant lifts arms togreet familiar people







MATERIAL: mirrorPROCEDURE:With the child in a sitting position, placea mirror in front of him and observe if hestares at or tries to get the mirror or patsit. Credit if the child can look or smileat the mirror, kiss or pat it with hishand or just turn it around.




Cries when caregiverleaves

Enjoys watchingactivities of nearbypeople or animals

Smiles playfully atmirror image

Friendly withstrangers but initiallymay show slightanxiety or shyness

Plays alone but likesto be near familiaradults or brothersand sisters

Laughs or squealsaloud in play


5.

6.

7.

8.

9.

10.

1st 2nd 3rd


B. Optional starting point for children aged 1 year and 1 month to 3.0 years






TOTAL SCORE

Plays peek-a-boo(bulaga)

Rolls ballinteractively withcaregiver/examiner

Hugs or cuddles toys

Responds withpleasure to friendlypeople


11.

12.

13.

14.

1st 2nd 3rd



Name of examiner : ________________________________________Date administered : ________________________________________Place where test is administered : ______________________________

To the examiner :Please fill out the spaces below for additional information. Thank you very much.Write down your notes, descriptions and observations on the following points:

Child’s background (ex. behavior/health/etc.)

_________________________________________________________________________________________________________________

________________________________________________________________________________________________

_________________________________________________________________________________________________________________

________________________________________________________________________________________________

_________________________________________________________________________________________________________________

Family environment (ex. Health of family members/family problems/economic conditions/etc.)

_________________________________________________________________________________________________________________

________________________________________________________________________________________________

_________________________________________________________________________________________________________________

________________________________________________________________________________________________

_________________________________________________________________________________________________________________

Parents’ stimulating activities for the child (What are the activities/things that the parents do to help stimulate the child’s develop-ment?)

_________________________________________________________________________________________________________________

________________________________________________________________________________________________

_________________________________________________________________________________________________________________

________________________________________________________________________________________________

Home environment (ex. Facilities/type of house/ household items/ interaction/etc.)

_________________________________________________________________________________________________________________

________________________________________________________________________________________________

_________________________________________________________________________________________________________________

________________________________________________________________________________________________

Others

_________________________________________________________________________________________________________________

________________________________________________________________________________________________

_________________________________________________________________________________________________________________

________________________________________________________________________________________________


Gross MotorFine Motor

Self-Help

Receptive LanguageExpressive Language

Cognitive

Social- EmotionalSum of Scaled Scores

Standard Score

Interpretation

Age

DomainChild’s Age

Raw Score Scaled Score

1st Evaluation Date:_____

Child’s AgeRaw Score Scaled Score

2nd Evaluation Date:_____


3rd Evaluation Date:_____

Gross Motor

Fine MotorSelf-Help

Receptive Language

Expressive LanguageCognitive

Social- Emotional

Sum of Scaled ScoresStandard Score

Interpretation

Age

DomainChild’s Age

Raw Score Scaled Score

4th Evaluation Date:_____





Transfer the raw score for each domain to the table below. Using the Scaled Score Equivalent of Raw Scores Table, convertthe raw scores to Scaled Scores appropriate to the age of the child. To arrive at the Sum of Scaled Scores, add the Scaled Scoresacross all domains. To derive the Standard Score, refer to the Standard Score Equivalent of Sums of Scaled Scores Table.Write the child’s age on each evaluation.


Scaled ScoresMark an x on the dot corresponding to the Scaled Score for each domain and connect the x’s. Write the child’s age on eachevaluation.

Child’s Age:

SCAL

ED S

CORE

GROS

S MO

TOR

FINE

MOT

OR

SELF

-HEL

P

RECE

PTIV

E LAN

GUAG

E

EXPR

ESSI

VE LA

NGUA

GE

COGN

ITIV

E

SOCI

AL-E

MOTIO

NAL

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5 • • • • • • •

4 • • • • • • •

3 • • • • • • •

2 • • • • • • •

1 • • • • • • •

DOMAIN

Child’s Age:

SCAL

ED S

CORE

GROS

S MO

TOR

FINE

MOT

OR

SELF

-HEL

P

RECE

PTIV

E LAN

GUAG

E

EXPR

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NGUA

GE

COGN

ITIV

E

SOCI

AL-E

MOTIO

NAL

19 • • • • • • •

18 • • • • • • •

17 • • • • • • •

16 • • • • • • •

15 • • • • • • •

14 • • • • • • •

13 • • • • • • •

12 • • • • • • •

11 • • • • • • •

10 • • • • • • •

9 • • • • • • •

8 • • • • • • •

7 • • • • • • •

6 • • • • • • •

5 • • • • • • •

4 • • • • • • •

3 • • • • • • •

2 • • • • • • •

1 • • • • • • •

DOMAIN

Child’s Age:

SCAL

ED S

CORE

GROS

S MO

TOR

FINE

MOT

OR

SELF

-HEL

P

RECE

PTIV

E LAN

GUAG

E

EXPR

ESSI

VE LA

NGUA

GE

COGN

ITIV

E

SOCI

AL-E

MOTIO

NAL

19 • • • • • • •

18 • • • • • • •

17 • • • • • • •

16 • • • • • • •

15 • • • • • • •

14 • • • • • • •

13 • • • • • • •

12 • • • • • • •

11 • • • • • • •

10 • • • • • • •

9 • • • • • • •

8 • • • • • • •

7 • • • • • • •

6 • • • • • • •

5 • • • • • • •

4 • • • • • • •

3 • • • • • • •

2 • • • • • • •

1 • • • • • • •

DOMAIN

Sugg

ests

adva

nced

dev

elop

men

t A

vera

ge d

evel

opm

ent

Re-

test

afte

r 3-

6 m

onth

s


Child’s Age:

SCAL

ED S

CORE

GROS

S MO

TOR

FINE

MOT

OR

SELF

-HEL

P

RECE

PTIV

E LAN

GUAG

E

EXPR

ESSI

VE LA

NGUA

GE

COGN

ITIV

E

SOCI

AL-E

MOTIO

NAL

19 • • • • • • •

18 • • • • • • •

17 • • • • • • •

16 • • • • • • •

15 • • • • • • •

14 • • • • • • •

13 • • • • • • •

12 • • • • • • •

11 • • • • • • •

10 • • • • • • •

9 • • • • • • •

8 • • • • • • •

7 • • • • • • •

6 • • • • • • •

5 • • • • • • •

4 • • • • • • •

3 • • • • • • •

2 • • • • • • •

1 • • • • • • •

DOMAIN

Child’s Age:

SCAL

ED S

CORE

GROS

S MO

TOR

FINE

MOT

OR

SELF

-HEL

P

RECE

PTIV

E LAN

GUAG

E

EXPR

ESSI

VE LA

NGUA

GE

COGN

ITIV

E

SOCI

AL-E

MOTIO

NAL

19 • • • • • • •

18 • • • • • • •

17 • • • • • • •

16 • • • • • • •

15 • • • • • • •

14 • • • • • • •

13 • • • • • • •

12 • • • • • • •

11 • • • • • • •

10 • • • • • • •

9 • • • • • • •

8 • • • • • • •

7 • • • • • • •

6 • • • • • • •

5 • • • • • • •

4 • • • • • • •

3 • • • • • • •

2 • • • • • • •

1 • • • • • • •

DOMAIN

Child’s Age:

SCAL

ED S

CORE

GROS

S MO

TOR

FINE

MOT

OR

SELF

-HEL

P

RECE

PTIV

E LAN

GUAG

E

EXPR

ESSI

VE LA

NGUA

GE

COGN

ITIV

E

SOCI

AL-E

MOTIO

NAL

19 • • • • • • •

18 • • • • • • •

17 • • • • • • •

16 • • • • • • •

15 • • • • • • •

14 • • • • • • •

13 • • • • • • •

12 • • • • • • •

11 • • • • • • •

10 • • • • • • •

9 • • • • • • •

8 • • • • • • •

7 • • • • • • •

6 • • • • • • •

5 • • • • • • •

4 • • • • • • •

3 • • • • • • •

2 • • • • • • •

1 • • • • • • •

DOMAIN

Sugg

ests

adva

nced

dev

elop

men

t A

vera

ge d

evel

opm

ent

Re-

test

afte

r 3-

6 m

onth

s


Re-

test

afte

r 3

to 6

mon

ths

Aver

age

deve

lopm

ent

Standard ScoresMark an x on the corresponding Standard Score for each test administration and connect the x’s. Write the date for each test administration.

AGE0-4 months 5-8 months 9-12 months 13-18 months 19-24 months 25-36 months

160

150

140

130

120

110

100

90

80

70

60

50

40

30

20

Date Tested

Sugg

ests

adv

ance

dde

velo

pmen

t

First PrintingJanuary 2004Manila, Philippines

NOT F

OR S

ALE

Documents

child form 1 - eccdcouncil.gov.ph Checklist Child s... · checklist. Some of the questions are for children older than your child so I do not expect him to be able to do all the things