Name: ______________________________ Nickname: ________________ Date of Birth:_________________________ Age: ________ Sex: _______ GROSS MOTOR DOMAIN GROSS MOTOR

PRESENT Climbs on chair or other elevated piece of furniture like a bed without help. Walks backwards Runs without tripping or falling. Walks down stairs, 2 feet on each step, with one held. Walks upstairs holding handrail, 2 feet on each step. Walks upstairs with alternate feet without holding handrail. Walks downstairs with alternate feet without holding handrail. Moves body parts as directed. Jumps up. Throws ball overhead with direction. Hops 1-3 steps on preffered foot. Jump and turn. Dances patterns/joins group movement activities. TOTAL SCORE FINE MOTOR DOMAIN FINE MOTOR Uses 5 fingers to get food/toys placed on flat surface. Picks up objects with thumb and index finger. Display a definite hand preference. Puts small objects in/out of containers. Holds crayon with all the fingers of his hand making a fist(i.e, palmar grasp) Unscrews lid of container or unwraps food. Scribbles spontaneously. Scribbles vertical and horizontal. Draws circle purposely. Draws a human figure( head, eyes, trunk arms, hand /fingers). Draws a house using geometric forms. TOTAL SCORE SELP-HELP DOMAIN SELP-HELP Feeds self with finger food(e.g, biscuits, bread) using fingers. Feeds self using spoon with spillage Feeds self using spoon without spillage.

4. 5. 6. 7. 8. 9. 10. 11. 12. 13. 14. 15. 16. 17. 18. 19.

COMMENTS

1. 2. 3. 4. 5. 6. 7. 8. 9. 10. 11. 12. 13

20.

21. PRESENT COMMENTS 22.

1. 2. 3. 4. 5. 6. 7. 8. 9. 10. 11.

23. 24. 25. 26. 27.

1. 2. PRESENT COMMENTS 3. 4. 5.

1. 2. 3.

Feeds self using fingers with spillage. Fedds self using fingers without spillage. Eats without need for spoonfeeding during any meal. Helps hold cup for drinking. Drinks from with spillage. Drinks from cup unassisted. Gets drink for self unassisted. Pours from pitcher without spillage. Prepares own food/snack. Prepares meals for younger siblings/family members when no adults is around. Participates when being dressed(e.g., raises arms or lifts leg). Pulls down gartered short pants. Redmoves sando. Dresses without assistance including buttons and tying. Dresses without assistance except for buttons and tying. Informs the adult only after he has already urinated (peed) or moved his bowels (poohed) in his underpants. Informs adult of need to urinate (pee) or moved bowels (pooh-pooh) so he can be brought to designated place (e.g. comfort room). Goes to the designated place to urinate (pee) or move bowels (pooh) and never does this is his underpants anymore> Goes to the designated place to urinate (pee) or move bowels (pooh) and never does does this is his underpants anymore. Wipes/clean self after a bowel movement.. Participates when bathing (e.g. Rubbing with soap). Washes and dries hands without any help. Washes face without any help. Bathes withou any help. TOTAL SCORE RECEPTIVE LANGUAGE RECEPTIVE LANGUAGE PRESENT Points to family members when asked to do so. Points to 5 body parts on himself when asked to do so. Points 5 named picturd objects when asked to do so. Follws one-step instructions that include simple prepositions (e.g. in, on, under, etc.) Follows 2-step instructions that include simple preposition.

1. 2. 3. 4. 5. 6. 7. 8.

1. 2. 3. 4. 5. 6. 7. 8. 9. 10. 11. 12. 13. 14. 15. 16. 17. 18. COMMENTS 19. 20. 21.

1. 2.

TOTAL SCORE EXPRESSIVE LANGUAGE DOMAIN EXPRESSIVE LANGUAGE PRESENT Uses 5-20 recognizable words. Uses pronouns (e.g. I, me, ako, akin) Uses 2-3 words verb-noun combinations (e.g. hingi gatas). Names objects in pictures. Speaks in grammatically correct 2-3 word sentences. Asks what questions. Aks who questions. Gives account of recent experiences (with prompting) in order of occurence using past tense. TOTAL SCORE COGNITIVE DOMAIN COGNITIVE PRESENT Looks at direction of fallen object. Looks dor partially hidden object. Immitates behavior just seen a few minutes earlier. Offers object but will not release it. Looks for completely hidden object. Exhibits simple pretend play (feed, put doll to slep). Matches objects. Matches 2-3 colors. Matches pictures. Sorts based on shapes. Sorts objects based on 2 attributes (e.g. size and color). Arranges objects according to size from smallest to biggest> Names 4-6 colors. Copies shapes. Names 3 animals or vegetables when asked. States what common household item are used for. Can assemble simple puzzles. Demonstrates an understanding of opposites by completing a statement (e.g. Ang aso ay malaki. Ang daga ay maliit.) Points to left and right side of the body. Can state what is silly on wrong with pictures (e.g. Ano ang mali sa larawang ito?) Matches upper and lower case letters. TOTAL SCORE SOCIAL EMOTIONAL DOMAIN SOCIAL-EMOTIONAL PRESENT Enjoys watching activities of nearby people or animals. Friendly with strangers but initially may show

COMMENTS

COMMENTS

COOMENTS

3. 4. 5. 6. 7. 8. 9. 10. 11. 12.

13. 14. 15. 16. 17. 18. 19. 20. 21. 22.

23. 24.

slight anxiety or shyness. Plays alone but likes to be near familliar adults or brothers and sisters. Laughs or squels aloud in play. Plays peek-a-boo (bulaga). Rolls ball interactively with caregiver/examiner. Hugs or cuddles toys. Demonstrates respect for elders using terms like po and opo. Shares toys with others. Immitates adult activities (e.g. cooking, washing) Identifies feelings in others. Appropriately uses cultural gestures of greeting without much prompting (e.g. mano, bless, kiss, etc.) Comforts playmates/siblings in distress. Persists when faced with problem or obstacle to his wants. Helps with family chores( e.g. wiping tables, watering plants, etc.) Curious about environment but knows when to stop asking questions of adults. Waits for turn. Asks permission to play with toy being used by another. Defends possessions with determination. Plays organized group games fairly (e.g. does not cheat in order to win). Can talk about difficult feelings (e.g. anger, sadness, worry) he experiences. Honors a simple bargain with caregiver (e.g. can play outside only after cleaning/fixing his room). Watches responsibly over younger siblings/family members. Cooperates with adults and peers in group situations to minimize quarrels and conflicts. TOTAL SCORE

JUNE Sum of Scaled Scores Standard Score Interpretation of Standard Score

OCTOBER

MARCH

Republic of the Philippines Department of Education Region IV MIMAROPA LUBANG INTEGRATED SCHOOL Lubang

Philippine Early Childhood Development Checklist

Form 2 (3.0-5.11 years old)

PARENTS/GUARDIAN NAME AND SIGNATURE

JUNE OCTOBER MARCH

Childs Name: Birthdate: LRN:

Age:

S.Y: 2013-2014 Sex: Male

ERMELITA T. VILLAR ES PRINCIPAL II

VANESSA V. NAZARENO TEACHER