GROSS MOTOR DOMAIN June March Remarks 8 Drinks from cup with spillage (e.g.

hingi gatas)
1 Climbed on chair or other elevated piece 9 Drinks from cup unassisted 4 Names objects in pictures
10 Gets drink for self-unassisted 5 Speaks grammatically correct 2-3
of furniture like a bed without help
2 Walks backwards
11 Pours from pitcher without spillage sentences
3 Runs without tripping or failing
12 Prepares own food/ snack 6 Asks “what” questions
13 Prepares meals for younger siblings/ 7 Asks “who” and “why” questions
4 Walks downstairs, 2 feet on each step,
with one hand held family members when no adult is 8 Gives account on recent experiences
5 Walks on stairs holding handrail, 2 feet around ( with prompting in order of occurrence
on each step
14 Participates when dressed(e.g. raises using past tense)
6 Walks upstairs with alternate feet arms or lift leg) TOTAL
15 Pulls down gartered short pants
without holding handrail
16 Removes sando COGNITIVE DOMAIN June March Remarks
7 Walks downstairs with alternate feet
17 Dresses without assistance except 1 Look at direction of fallen objects
without holding handrail
8 Moves body part as directed button and tying 2 Looks for partially hidden objects
18 Dresses without assistance including 3 Imitates behavior just seen a few
9 Jumps up
10 Throws ball overhead with direction button and tying minutes earlier
19 Informs adult only after he/ she has already 4 Offers object but will not release it
11 Hops 1 t0 3 steps on preferred foot urinated (pee) or move his bowel (poohed) in
12 Jumps and turn 5 Looks for completely hidden objects
his underpants
13 Dances patterns, joins group movement 20 Informs adult of need to urinated(pee) or 6 Exhibits simple pretend play (feed, put
activities move bowels (poohed) so he can be bought to doll to sleep)
TOTAL designated place (e.g. comfort room) 7 Matches objects
21 Goes to designated place to urinate or move 8 Matches 2-3 colors
bowels and but sometimes still does this in his 9 Matches pictures
underpants
FINE MOTOR DOMAIN June March Remarks 10 Sorts based on shapes
22 Goes to designated place to urinate or move
11 Sorts objects based on 2 attributes (e.g.
1 Uses all fingers to get food/ toys placed bowels and never does this in his underpants
on flat surface anymore size and color)
23 Wipes/ clean self after a bowel movement 12 Arranges objects according to size from
2 Picks up objects with thumbs and index
(pooh) smallest to biggest
finger
24 Participate when bathing (e.g. rubbing arms 13 Names 4-6 colors
3 Displays definite hand preference with soap) 14 Copies shapes
4 Puts small objects in/ out of container 25 Washes and dries hands without any help
15 Names 3 animals or vegetables when
5 Hold crayons with all the fingers of his 26 Washes face without any help
hand making a first (e.g. palm grasp) asked
27 Bathes without any help 16 States what common household items
6 Unscrew lid of container or unwraps TOTAL
food are used to
17 Can assembled simple puzzles
7 Scribbles spontaneously
RECEPTIVE LANGUAGE DOMAIN June March Remarks 18 Demonstrate and understanding of
8 Scribbles vertical and horizontal
9 Draws circle purposely 1 Points to family member when asked to opposites by completing a statement
10 Draws human figures (head, eyes, do (e.g. “Ang aso ay malaki, Ang daga ay
trunks, arms, hand/finger) 2 Points to 5 body parts on himself when ____”)
19 Points to left and right sides of body
11 Draws a house using geometric forms asked to do
3 Points to 5 named picture objects when 20 Can state what is silly or wrong with
TOTAL
asked to do pictures (e.g. Ano ang mali sa larawang
4 Follows one-step instruction that include ito?”)
SELF-HELP DOMAIN June March Remarks simple preposition (e.g. in, on, under) 21 Matches upper and lower case letters
1 Feeds self with finger food (e.g. biscuits, 5 Follows 2-steps instruction that include TOTAL
bread) using fingers simple preposition
2 Feeds self-using fingers with spillage TOTAL SOCIAL-EMOTIONAL DOMAIN Jun Mar Remarks
3 Feeds self-using spoon with spillage 1 Enjoys watching activities of nearby people or
4 Feeds self-using fingers without spillage animals
EXPRESSIVE LANGUAGE DOMAIN June March Remarks
5 Feeds self-using spoon without spillage 2 Friendly with strangers but initially may show
1 Uses 5-20 recognizable words
6 Eats without need for spoon feeding slight anxiety or shyness
2 Uses pronoun (e.g. I, me, ako, akin)
during any meal 3 Plays alone but like to be near family adults or
3 Uses 2-3 words verb noun combinations
7 Helps hold cups for drinking brothers and sisters
4 Laugh or squeals aloud in play 1st Interview JUNE 4.1-5 5.1-6 Department of Education
5 Play peek-a-boo (bulaga) Caraga Administrative Region
6 Rolls ball interactively with caregiver/ examiner
7 Hugs or cuddles toys
Division of Butuan City
DOMAIN RS SS RS SS South West District
8 Demonstrates respect for elder using terms like Gross Motor
“po” and “opo” MANDACPAN ELEMENTARY SCHOOL
Fine Motor
9 Shares toys with others San Vicente, Butuan City
10 Self-Help
Imitates adult activities (e.g. cooking and
Receptive Language
washing) PHILIPPINE EARLY CHILDHOOD CARE AND
11 Identifies feelings of others Expressive Language
12 Appropriately uses cultural gesture of greeting without
DEVELOPMENT (ECCD) CHECKLIST
Cognitive
much prompting (e.g. mano, bless, kiss, etc.) S.Y. _________
13 Social Emotional
Comforts playmates/ sibling in distress
14 Persist when faces problems or obstacles to his Sum of Scaled Score
Standard Score (+15)
Name: LRN:
wants
15 Helps with family chores (e.g. wiping table,
watering plants) Interpretation Birthdate: Age: As of:
16 Curious about environment but knows when to
stop asking questions of adults
17 Waits for turn Date of Exam
Handedness: Left Right Both Sex
18 Asks permission to play with toy being used by Date of Birth
another Age as of Interview
19 Defends possessions with determination Para Sa Mga Magulang:
20 Plays organized group games fairly (e.g. does not
cheat in order to win) Ang Philippine Early Childhood Care and Development
21 Can talk about difficult feelings (e.g. anger, Checklist ay nagtataglay ng mga kakayahan, ugali at kaalaman
2ndInterview March 4.1-5 5.1-6
sadness, worry) he experiences ng mga batang 5 taon gulang. Ito ay maaaring gamiting gabay sa
22 Honors a simple bargain with caregiver (e.g. can pagkilala ng inyong anak at sa kalaunan ay makagawa ng angkop
play outside only after cleaning/ fixing his room) na pag alaga, pagturo at paggabay sa kanilang pagpalaki at pag-
23 Watches responsibly over younger siblings/ DOMAIN RS SS RS SS
Gross Motor unlad.
family members
Fine Motor
24 Cooperates with adults and peers in group Nilalaman:
situations to minimize quarrels and conflict Self-Help
TOTAL Receptive Language  Gross Motor Domain – 13 items
Expressive Language  Fine Motor domain – 11 items
 Self-Help Domain – 27 items
PARENTS SIGNATURE Cognitive
Social Emotional  Receptive Language Domain – 5 items
Sum of Scaled Score  Expressive Language Domain – 8 items
Standard Score (+15)  Cognitive Domain – 21 items
JUNE:_________________  Socio- Emotional Domain – 24 items

Interpretation Iskor:
________________ (/) kaya o alam gawin ng bata
Date Date of Exam (-) di-kaya o di nasagot
Date of Birth _______________________
Age as of Interview Kindergarten Teacher
MARCH: __________________ RAUL L. MAHILUM_
Principal II
________________
Date
Republic of the Philippines