Name of Evaluator/Observer _____________________________________________________________

Address ______________________________________________________________________________

Occupation ___________________________________________________________________________

Part I. Screening Device for the Use of Laymen

Directions: Here are some common characteristics observed among mentally retarded children. Put a
check mark (√) opposite each of the items if you find the characteristics in the child being observed.

A. Physical and Motor Characteristics

Observed

1. Is slightly lighter in weight d. Wide face _________

than most children of his e. Disproportionately
own group _________ short hands and fingers _________
2. Is shorter in height than f. Broad hands with
most children of his own fingers having ends _________
age group _________ g. Teeth that are pegshaped
3. Walks with stooping and chalky _________
shoulders_________ h. Swollen eyelids and eyes
4. Walks with uncoordinated that are half-shut _________
swaying of the arms _________ i. Short thick neck _________
5. Tendency to trip or stumble j. Short thick legs _________
over objects while k. Large head _________
walking _________ l. Disproportionately small
6. Tendency to drop objects head _________
and articles _________ m. Dry, course and scaly
7. Has difficulty in maintaining skin _________
balance while jumping, hopping
and skipping _________ Sub-Score _________
8. Has difficulty in using
scissors _________ B. Personal/Social Characteristic
9. Has difficulty in using knives
for slicing, paring, and
cutting _________ 1. Tendency to be alone most
10. Finds difficulty in tying of the time _________
shoelaces, ribbons or 2. Easily cries _________
sash _________ 3. Tendency to get angry at a
11. Is unable to hold pen or pencil slight provocation _________
correctly _________ 4. Lacks concern and attention
12. Has difficulty in tracing circle,
square and triangle_________
 13. Has difficulty in drawing a to events and people around
circle _________ him _________
14. Has difficulty in drawing a 5. Talks and laughs in an
square _________ unnecessarily loud
15. Has difficulty in drawing a voice _________
triangle _________ 6. Tendency to over react to
16. Finds difficulty in writing letters events and people around
of the alphabet _________ him _________
17. Finds difficulty in writing 7. Does not care about the
numbers _________ feeling of others _________
18. Has the following physical 8. Does not laugh easily when
deformities: _________ confronted with funny
a. Slanted eyes with situations _________
coordinated eye 9. Is unable to take care of
muscles _________ himself in comparison with
b. Protruding forehead children of his own age
situations _________ group in following activities _________
c. Large protruding
tongue _________

C. Learning Characteristics D. Spoken Language

_________1) Has short attention span _________1) Refuses to talk

Has poor memory _________2) Has the tendency
_________2) Has difficulty in comprehending to speak in words
situations in communication or phrases instead
_________3) Is easily distracted _________3) Tendency to talk
_________4) Has difficulty in finishing in sentences with
work that has been started grammatical errors
_________5) Perseverates or repeats _________4) Has immature or
unnecessarily an action improper vocabulary
_________6) Has reversals in written work _________5) Tendency to have
_________7) Has difficulty in relating articulation problems
isolated facts into meaningful ideas such as:
a. Omissions
b. Substitutions
c. Additions
d. Distortions
_________6) Gropes for words to express himself
 Development Milestone

AGE BEHAVIOR

0-3 months 1. Lifts head when placed on his stomach

2. Looks at object place 6-12 inches from his
eyes.
3. Listens to noises and sounds.
4. Makes sounds.
5. Cries when hungry and wet.
4 - 6 months 6. Smiles at anybody when happy.
7. Holds head straights in sitting position or
when pulled up from lying position.
8. Lying on stomach, holds head and chest up.
9. Rolls over.
10. Grasps with whole hand, reaches out.
11. Holds and feeds himself alone with biscuits
or chrackers.
12. Attached to mother - sad when whe leaves,
happy when she is close.
13. Able to show when he is happy or upset.
14. Looks for toys, notice things far away.
15. Stands with help.
16. Sits alone, crawls.
17. Holds things with fingers and thumbs.
18. Turns head toward person calling his name.
19. Says "Mama" or "Dada" without meaning.
20. Waves bye-bye or claps his hands.
21. Afraid of strangers, happy with familiar
faces.
12 - 17 months 22. More playful.
23. Stands alone.
24. Walks with help.
25. Imitate words, sounds just heard.
26. Picks up small things with index finger and
thumb.
27. Expresses what he wants.
28. Calls "Mama" to mother, "Papa" to father.
29. Holds arms out asking for attention.
30. Rolls ball to adult playing with him.
31. Understands what is being said and
becomes demanding.
2 years old 32. Walks and jumps well.
33. Bends and squats without support
34. Scribbles.
35. Able to put curbes one on top of another,
36. Says more words and phrases.
37. Points to parts of body asked.
 38. Removes shoes or pants without help.
39. Stingy,possesive over toys.
40. Competes for attention.
41. Insists on what he wants.
42. Plays alone for periods of time.
43. Balances on one foot without supports for
a few seconds.
44. Climbs stairs alone.
45. Draws a vertical line.
46. Builds tower of 8 cubes.
47. Does simple errands.
48. Uses plurals correctly.
49. Can dress with supervision, does simple
errands.
50. Names pictures shown to him.
51. Able to play with others and wait for his
turn.
52. More comfortable with strangers.
53. More aware of what he can and cannot do.
4 years old 54. Tolerated absence of caretaker.
55. Balances on one foot longer.
56. Skills and hops.
57. Bathes with supervison
58. Copies a circle or cross correctly.
59. Carries on conversations with others and
imitate people and animals.
60. Likes to listen to stories and asks questions.
61. Competes for attention of parents of the
opposite sex.
62. Knows differences between the sexes,
touches genitals.
63. Likes "makes believe games".
64. Shows expression using hands and face.
65. Controls bladder and bowel habit.
5 years old 66. Likes to jump and swing.
67. Catches ball bounced towards him, using
his hands.
68. Dresses alone, can button or snap on dress.
69. Copies a square.
70. Knows at least 4 colors - different colors.
71. Knows different shapes and sizes.
72. Able to give his first name and last name
when asked.
73. Is curious about things around him find
outs, listening, looking and touching.
74. Shows independence and self-importance.
75. Pays more attention to playmates, prefers
friends of the same sex.
 76. Likes to play "domestic roles" (bahay-
bahayan)
6 years old 77. Coordinates movements very well- jumps,
swings, rounds, climbs, errands.
78. Goes on an errand with others.
79. Takes a ride.
80. Copeis a triangle.
81. Shows interest in nature.
82. Uses polite expression.
83. Explains the things that he is doing.
84. Shows interests in letters and numbers.
85. Goes to school.
86. Begins to feel like one of the group.
87. Likes grown up companies.
88. Likes playmates of the same sex.
89. Expresses emotions in acceptable way, can
control feelings.
90. Knows difference between what he wants
and what he should do.
91. Competes actively with others.
92. Greets peers and familiar adults.
93. Goes on an errand independently.