TEACHERS GUIDE IN SCREENING of LWDs. FINAL 1

Republic of the Philippines
Department of Education
REGION XII - SOCCSKSARGEN
SCHOOLS DIVISION OF SOUTH COTABATO
DISTRICT
SCHOOL
SCHOOL ADDRESS
PROJECT
(Screening, Evaluation,and Assessment

of Learner’s with Disabilities)
(Teacher’s Guide)
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Address: Purok_ , Barangay , Municipality
ool Telephone Number: (083)
Lo Email Address: _@deped.gov.ph
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For the Teachers:
The goal of screening, assessment, and evaluation is to identify which learners will be enrolled in
special education classes. Screening, assessment, and evaluation are of chief importance in determining the
category of disability to which a child belongs. Systematic, valid, and reliable methods for identifying
learners with disabilities are paramount. The screening, assessment, and evaluation results serve as the basis
for determining the education program and the educational goals it can achieve. The program and services
will allow them to maximize their potential and capacity.
Location and screening of learners with disabilities eliminate learners who are not likely to be
disabled and identify those who either show signs of a particular disability or seem to be at risk for
developing the disability. Learners who complete the screening undergo a more thorough and formal
assessment, including trained staff's standardized psychological tests.
Suppose there are no qualified professionals to conduct the psychodiagnostics evaluation of LWD;
valid and reliable multi-factored assessment devices are used to determine special education eligibility
among learners who pass the initial screening. The multi-factored evaluation or final screening phase aims to
collect all the information and data about the learner. Assessment and screening results are carefully
evaluated to determine if the learner exhibits learning and behavioral characteristics in a specific category.
The learner can be in a special education class if the learning and behavioral characteristics are
manifestations.
The checklists, grading scales, observations, interviews, and questionnaires are not expected to pass
the standardized tests. For this reason, referral or psychodiagnostics assessment is recommended when the
learner is considered eligible for special education and is admitted to the SPED program. Individualized
Education Program (IEP) is prepared for learners with severe disabilities as much as possible through IEP is
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preferred for all learners. Then, decisions are made on the SPED services each learner needs and the
appropriate placement in the regular class.
Location and screening of learners with disabilities eliminate learners who are not likely to be
disabled and identify those who either show signs of a particular disability or seem to be at risk for
developing the disability. Learners who complete the screening undergo a more thorough and formal
assessment, including trained staff's standardized psychological tests.
INDIVIDUAL LEARNER’S PROFILE
PART 1
Name: Date of Birth: Age:

Home Address:
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Type of Learner: LRN:

School Year: Adviser:
Principal:
Record of Assessment:
Type of Date Chronological Administrator Results/Outcome
Assessments Administered Age
Interview with Parents/Guardian

Name of Parent/Guardian:
Contact Number/s:
Developmental and Educational History
Interview with the Learner

Date of Interview:
Interests/ Hobbies/ Talents
DAILY LIVING SKILLS DOMAIN: Present Level of Educational Performance

Strength/s:
Need/s:
LANGUAGE DEVELOPMENT DOMAIN: Present Level of Educational Performance

Strength/s:
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Need/s:
PSYCHOMOTOR DOMAIN: Present Level of Educational Performance

Strength/s:
Need/s:
COGNITIVE DOMAIN: Present Level of Educational Performance

Strength/s:
Need/s:
AESTHETIC AND CREATIVE DOMAIN: Present Level of Educational Performance

Strength/s:
Need/s:
BEHAVIORAL DEVELOPMENT: Present Level of Educational Performance

Strength/s:
Need/s:
ORIENTATION AND MOBILITY: Present Level of Educational Performance

Strength/s:
Need/s:
PART 2
Priority Learning Needs/Interventions:
1.
2.
3.
4.
5.
Transition Package:
1.
2.
3.
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4.
5.
Step 1: Pre-referral Intervention/Initial Screening
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The first stage consists of a referral procedure or initial screening. The pre-referral intervention
focuses on locating learners in regular classes and the community who may need special education. Initial
screening can prevent or reduce future problems by strengthening the parent's and regular teachers' capacity
to intervene effectively with learners with disabilities that are not adequately met in a home and regular
classes. The initial screening results determine whether the learner should be referred to the formal multi-
factored assessment or whether he or she can learn in a regular class.
The primary process is teacher nomination as well as nomination by parents and significant others.
Checklists on learners' learning and behavior characteristics, observation, and interviews are used. A learner
who fails the initial screening phase does not demonstrate a learner's learning and behavior characteristics
with a particular disability. The learner continues to participate in the regular class. In the meantime, a
learner with half or more than 50 percent of the characteristics may have a disability.
Form 1: Teacher Nomination (TN)
Directions:
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Read the checklist thoroughly. List your learners with most (more than half) of the characteristics in
the checklist. Ask the SPED team members to explain the items that are not very clear to you.
Name Grade Age Teacher
1.
2.
3.
4.
5.
6.
7.
8.
9.
10.
Prepared by:
Teacher’s Name & Signature

Date:
Form 2a: Checklist in Learning and Behavior Characteristics

(CLBC)
CHARACTERISTICS Sometimes Most of the Time All the Time
(1 point) (2 points) (3 points)
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I. Learning Characteristics
A. Spelling
1. Uses incorrect letter order
2. Cannot spell correctly at grade level
3. Cannot write from dictation at grade level
4. Reverses letters or entire words
B. Writing
1. Cannot write name or other _information
2. Cannot stay on line
3. Cannot copy simple sentences from

the board
4. Cannot write simple sentences
from dictation
5. Cannot do regular work in writing for
the grade
C. Reading
1. Does not like to read
2. Loses place when reading
3. Repeats, omits or adds words
4. Cannot read the DOLCH words
5. Uses fingers to follow lines
6. Cannot understand/remember what he/she

reads
D. Mathematics
1. Has difficulty associating numbers with
symbols
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SCHOOLS DIVISION OF SOUTH
COTABATO
DISTRICT
SCHOOL
II. Behavior Characteristics
1. Tends to be impulsive, hits classmates,
reacts immediately to situations
without
thinking, impatient; cannot wait for
his/her turn
2. Demands individual attention through
overt behavior tactics
3. Rushes through assignments with little or
no regard for accuracy, quality of work
2. Reverse two-place
numbers (13 or 31 vice
versa)
3. Cannot recall math facts at grade level
4. Fails to comprehend math concepts
5. Get confused with written and/or oral

arithmetic
E. Hearing/Speech
1. Does not seem to listen when spoken to
2. Cannot follow oral direction
3. Has articulation problem; wrong

pronunciation of words; speech not clear
4. Has infantile (baby Speech)
F. Psychomotor
1. Displays poor motor coordination in
using scissors, crayons, pencils etc.
2. Confuses right from left and vice versa
3. Lacks rhythm in movement, loses

sequence and balance; has
difficulty walking straight line
4. Has difficulty buttoning, zipping and
snapping articles of clothing; skipping,
hopping, climbing
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and neatness
4. Does not direct attention to or cannot
maintain attention to important sounds Additiona
in l
other activities, sits, and does nothing
5. Has short attention span, has difficulty Informati
concentrating on tasks on about
6. Stays out of seat; engages in over
the
Learner
Scoring and Interpretation of Results
Scoring Procedure:
1. Add the number of checkmarks in each column and multiply the sum by the number of
points. Sometimes x 1 point
Most of the time x 2 points
All the time x 3 points
2. Write the score using the following ranges and interpretation.
Interpretation:
75-105 points = Manifest almost all of the learning disability characteristics

Recommended for multi-factored assessment
50-74 points = Manifest most all of the learning disability characteristics

Recommended for multi-factored assessment
35-below points= Manifest some of the learning disability characteristics

Can benefit from regular class instruction
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Screened by:
Signature over printed name
Date:
Form 2b: Summary Report on Pre-Referral Screening

(SR-RPS)
Direction: Write the names, grade levels, and ages of the pupils who passed the pre-referral phase. Write the
scores obtained in the initial screening tools.
Name Grade Level Age Score Remarks
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1.
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2.
3.
4.
5.
6.
7.
8.
9.
10.
Prepared by:
Date:
Form 2c: Individual Report on Pre-Referral Screening

(IR-PRS)
Name:
Grade: Age:
School:
Address:
Name of Parents:
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Initial Screening Score: Interpretation:

Learning Characteristics:
Behavioral Characteristics:
Recommended for multi-factored assessment: Yes No

Other Observations:
Prepared by:

Date:
Step 2: Multi-factored Assessment: Final Screening and Identification of LWD
Learners who pass the screening phase are recommended to undergo a nondiscriminatory multi-factored
assessment. The school or the parents may request that a learner be assessed for special education. Regardless of the
referral source, parents must be notified of the school's intent to test their children and consent to the assessment.
A battery of tests is administered to collect information about a child's developmental history, mental abilities,
social and emotional characteristics, and academic performance. The multi-factored evaluation results are reviewed,
and decisions are made on which learners are eligible for special education. When the learners are identified in the
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SPED program, the rest of the steps in special education are implemented, namely, the development of educational
placement and review and evaluation.
Form 3: Child’s Profile: Case History Record (CHR)

CHILD’S PROFILE
I. GENERAL
Father’s Name: Age:
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Birthday: Birthplace: Citizenship:

Address:
Education Completed:
Occupation: Position Held:
Name of Present Employer:
Office Address:
Mobile Phone Nos. Work Phone:
Mother’s Name: Age:

Birthday: Birthplace: Citizenship:
Address:
Education Completed:
Occupation: Position Held:
Name of Present Employer:
Office Address:
Mobile Phone Nos. Work Phone:
Brothers/Sisters
Name: Age:
Age:
Name: Age:
Age:
Name: Age:
Age:
Name:
Name:
Name:
Presence of (M for Mother for Father, S for Siblings for Grandparents, R for other Relatives)
 Hearing Loss:  Mental Retardation:
 Epilepsy:  Substance Abuse:
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 Fragility: * Vision Impairment:
* Mental Illness:
* Autism:
* Clinical Depression:
 Speech Impairment (please specify):
 Behavior Problems (please specify):
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 Academic Difficulty (please specify):

 Specific Learning Disorder (please specify):
 Others (please specify):
DEVELOPMENTAL HISTORY
A. History
Age of mother at child’s birth: Age of father at child’s birth:

Pregnancy length: Was labor induced: Yes No
Birth Weight:
Were there any accidents, illnesses, infections, special tests or stress during the pregnancy or delivery? (Please
explain)
Did the infant have any difficulty breathing, crying and sucking? (Please explain)
Did the infant have jaundice, convulsions, blood incompatibility, etc.? (

Please explain)
B. Birth
Was the baby full term? Premature?
Was it difficult to labor?
Was delivery normal? Or by caesarian section?
What anesthesia was used (if any)?
When: Were instruments used to assist normal delivery:
Did the baby suffer from lack of oxygen?
Did the baby cry right away after birth?
Did the baby appear normal at birth?
C. Illnesses/ Injuries
Condition Age Description

Allergy
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Ear Infection
Encephalitis
Epilepsy
Fainting Spells
Hearing Problems
High Fever
Muscular Disease
Seizure
Syndromes
Tonsillectomy
Traumatic Brain Injury
Brain Problems
Describe any accidents or operations including dates:

List any medications prescribed to the child:
Were high doses of antibiotic/s ever prescribed?
If “yes” when: What antibiotic/s:
Why were they prescribed?
During the first two years, did the child ever have prolonged high fever? (If yes, please explain)
What preventive measures i.e., immunization, vaccinations, etc. have been taken?
Has the child any serious reactions to immunization?

If so, when?
Operations performed and reasons for these:
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D. Present Physical Condition
Allergies:
Preference for right and left:
Noticeable problems in coordination:
Does the child fall easily? Yes No
Does the child drool excessively? Yes No
Does the child over-perspire? Yes No
Does the child seem stress? Yes No
Does the child have normal vision? Yes No
Does the child have normal breathing pattern? Yes No
Does the child sniff food or objects frequently? Yes No
Illnesses Date Complication Name and Address of Attending

Physician
E. Motor Milestones
Indicate the age at which the following occurred:

 Rolled over * Fed Self *Walked unaided
 Sat alone * Toilet trained * Dressed self
 Crawled * Handedness
F. Speech/Language Development
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Indicate the age at which the following

occurred: Cooing: Babbling:
First words:
Vocabulary of 50 words: Understood: Said:
Two-word combinations: (e.g., more milk, me do, no go)
Short Sentences: (e.g., Ma want juice, Mommy do it)
Receptive and Expressive language Skills
Please answer “yes”, “no” or “sometimes” to the following questions:

1. Does your child respond to his/her name?
2. Will your child get common objects when asked?
3. Does your child follow simple directions-
If you use gestures?
If you do not use gestures?
4. Does your child use gesture?
5. Will your child point to pictures as you name them?
6. Does your child label picture?
7. Does your child repeat or “echo” other’s utterances?
8. Does your child repeat question or parts of questions, songs, television programs?
9. Has your child said a few times, then, never used it again?
10. Did language development seem to stop?
If yes, when?
11. Does anyone in the household speak a language other than your dialect?
If yes, what dialect/s?
12. How does your child make his/her needs/wants known to you?
13. How does your child indicate he/she doesn’t want something or does not want to do something?
14. What words/sentences does your child say independently (not reciting without your prompting or modeling)?
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15. Has your child ever had an audio logical evaluation (hearing test)?
If yes, when and where?
16. Has your child ever had any speech/language testing?
17. Has your child had a speech/language therapy?
G. BEHAVIORAL INFORMATION
1. Infancy
Was a silent infant Yes No Sometimes
Was an inconsolable infant Yes Sometimes
No
Was “too happy “as an infant Yes No Sometimes

Rarely cried Yes Sometimes
No
Did not desire interaction/affection Yes No Sometimes

Comments:
2. Play
Prefers to play alone Yes No Sometimes
Plays poorly with other children or does not interact with others?
Yes No Sometimes
Frequently line items in a row? Yes No Sometimes
Protests if line or items is interrupted? Yes No Sometimes

Holds (clutches) items for an extended period of time?
Yes No
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Sometimes
Frequently counts (objects, items, actions, etc.)
Yes No Sometimes
Has unusual interest (strips of paper, electrical cords, etc.)

Yes No Sometimes
Waves long objects back and forth?

Yes No Sometimes
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Spins objects? Yes No Sometimes
Circle any of the following which applies to your child’s play:

Repetitive With small group Messy
Imaginative Fantastic As a leader
Cooperative With toys As a follower
With peer group Flitting Others
With older children Engrossed
Comments:
3.Conduct
Is difficult to manage? Yes No Sometimes
Has a behavior problem? Yes No Sometimes
Displays temper tantrums? Yes No Sometimes
Had catastrophic reaction when told” no” Yes No Sometimes
Discipline is ineffective? Yes No Sometimes
Is overly active? Yes No Sometimes
Has a short attention span? Yes No Sometimes
Is aggressive towards self? Yes No Sometimes
Is aggressive toward others? Yes No Sometimes
Is destructive with objects? Yes No Sometimes
Check any of the following that describes the child:

negative manipulative fearful
quiet passive destructive
excitable leader aggressive
active friendly happy
self-centered predictable generous
sad suggestible stubborn
confident unresponsive temper-tantrum
lacks confidence others
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Comments:
4.General
Direction: please check the appropriate box:
Is withdrawn Yes No Sometimes
Grinds teeth Yes No Sometimes
Rocks back and forth Yes No Sometimes
Frequently spins in circles Yes No Sometimes
Has difficulty with change/transitions Yes No Sometimes
Protests when dressing/undressing Yes No Sometimes
Acts as if deaf Yes No Sometimes
Acts as if “in her/his own world” Yes No Sometimes
Ignores someone talking to him/her Yes No Sometimes
Covers ears with his/her hands Yes No Sometimes
Has limited eye contact Yes No Sometimes
Repeatedly turns light on /off Yes No Sometimes
Stares at his/her fingers/hands Yes No Sometimes
Stares intently at people or objects Yes No Sometimes
Stares in the mirror for long period of time Yes No Sometimes
Has strong preferences for/ responses to specific colors

Yes No Sometimes
Has strong preferences for specific food temperature, shape, color, texture etc.
Yes No Sometimes
Comments:
5.Fears
Climbs without fear Yes No Sometimes
Has unusual fears (specific animals, places, noises, colors etc.)
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Yes No Sometimes
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Exhibits age-appropriate fears (separation, being lost, darkness, etc.)

Yes No Sometimes
Comments:
HOME SITUATION
Has the child always lived with both parents? Yes No Sometimes
Has there been sudden departures or deaths in the immediate family?
Yes No Sometimes
Are there or has there been any serious illness in the family?
Yes No Sometimes
OTHER INFORMATION
Please provide other information that you feel would help us better plan for your child’s assessment.
Do you have any particular question you would like to ask?
Name of person completing this form:

Relationship to the child: Signature: Date:
Prepared by:

Date:
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Form 4: Learner’s Scholastic Ratings (LSR) and

Form 5: Least Learned Skills (LLS)
Direction: Write the scholastic ratings at least two grade levels and other information in the learner’s permanent
school records or Report Card.
Subjects Scholastic Ratings in Previous Grade Levels Least Learned Subjects
(Please check)
Remarks and Recommendations:
Prepared by:
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Date:
Form 6: Portfolio of School Work (PSW)
Direction:
1. Inspect the content of the portfolios and write a brief report on the learner's accomplishments.
2. On a scale of 1-10, with one as the lowest and ten as the highest, rate the learner's portfolio.
Scoring and Interpretation:
8 to 10 =Very Satisfactory
5 to 7 = Satisfactory
1 to 4 = Needs Improvement
Screened by:

Date:
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Form 7a: Assessment Checklist on Difficulty in Seeing
No.  /x Totally Blind

1 Lack of usable vision.
2 Receive no stimuli from their visual channel.
3 Depend entirely on input from other senses such as touch, hearing, smelling, and tasting.
4 The sense of touch is very keen.

5 Move slowly and carefully due to the fear of bumping into things or objects.
6 Move, feel, and touch objects, especially when traveling, to ensure they are on the right path.
7 Lack of light perception.
8 Use tactile and auditory channels for learning and functional tasks.
9 Use cane for mobility.
10 Learn via Braille and other non-visual media.
No.  /x Low Vision/ Partially-sighted

1 Have vision between 20/70-20/160 and cannot be corrected.
2 Use correctional glasses and
contact lenses.
3 Uses tactile and auditory channels for learning.
Screened by:
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COTABATO
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Date:
Form 7b: Assessment Checklist on Difficulty in Hearing
No.  /x Learning Characteristics
1 Show restrained expression when listening.
2 Less responsive to noise, voice or Music.
3 Watches faces especially the mouth and lips of the speaker.
4 Often asks for repetition when talked to.
5 Delayed or no response to questions.
6 Makes use of natural gestures, signs and movements.
7 Cocks ear/tilts head at an angle.
8 Cups hands behind the ear to catch sound.
9 Pays more attention to vibration and vibrating objects.
10 Moves closer to the speaker when talked to.
11 Fails to respond oral questions.
12 Shows marked imitativeness at work or play.
13 Has blank facial expression.
14 Often unable to follow directions/instructions.
15 Has difficulty in associating concrete with abstract ideas.
Screened by:
Date:
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Form 7c: Assessment Checklist on Difficulty in Basic

Learning and Applying Knowledge
1 Difficulty learning connections between letters and sounds
2 Confused in short words (at and to)
3 Letter reversals
4 Word reversals
5 Frequently adds and/or forgets letters in a word
6 Difficulty in remembering simple sequences
7 Difficulty keeping in place when reading
8 Poor sequencing of numbers
9 Poor spelling
10 Avoids reading aloud
11 Difficulty organizing ideas to speak or write
12 Avoids writing tasks
13 Left and Right confusion
14 Slow to memorize tasks and math
15 Trouble following oral instructions
16 Appearing restless or easily distracted
17 Difficulty in reading
18 Difficulty in writing
19 Difficulty in spelling
20 Difficulty in counting and calculating
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Screened by: Date:

Form 7d: Assessment Checklist on Difficulty in
Remembering and Concentrating
No.  /x Physical and Motor Characteristics
1 Is slightly lighter in weight than most children of his/her own group
2 Is shorter in height than most children of his/her own age group
3 Walks with stooping shoulders
4 Walks with uncoordinated swaying of the arms
5 Tendency to trip or stumble over objects while walking
6 Tendency to drop objects and articles
7 Has difficulty in maintaining balance while jumping, hopping, and skipping
8 Has difficulty in using scissors
9 Has difficulty in using knives for slicing, paring, and cutting
10 Finds difficulty in tying shoelaces, ribbons or sash
11 Is unable to hold pen or pencil correctly
12 Has difficulty in tracing circle, square and triangle
13 Has difficulty in drawing a circle
14 Has difficulty in drawing triangle
15 Has difficulty in drawing square
16 Has difficulty in writing letters of the alphabet
17 Finds difficulty in writing numbers
18 Has the following physical deformities
 Dry, course and scaly skin
 Slanted eyes with coordinated eye muscles
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 Protruding forehead
 Large protruding tongue
 Wide face
 Disproportionately short hands and fingers
 Broad hands with fingers having square ends
 Teeth that are peg shaped and chalky
 Swollen eyelids and eyes that are half-shut
 Short thick neck
 Short thick legs
 Large head
 Disproportionately small head
No.  /x Personal and Social Characteristics

1 Tendency to be alone most of the time
2 Easily cries
3 Tendency to get angry at a slight provocation
4 Lacks concern and attention to events and people around him
5 Talks and laughs in an unnecessarily loud voice
6 Tendency to over react to events and people around him
7 Does not care about the feelings of others
8 Does not laugh easily when confronted with funny situations

1 Has short attention span
2 Has poor memory
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3 Has difficulty in comprehending situations in communication

4 Is easily distracted around him/her
5 Has difficulty in finishing work that has been started
6 Perseverates or repeats unnecessary action
7 Has reversals in written work
8 Has difficulty in relating isolated facts into meaningful ideas
No.  /x Spoken Language

1 Refuses to talk
2 Has the tendency to speak in words or phrases instead
3 Tendency to talk in sentences with grammatical errors
4 Has immature or improper vocabulary
5 Tendency to have articulation problems such as:
a. omissions
b. substitutions
c. additions
d. additions
6 Gropes for words to express himself
Screened by:
Date:
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Form 7e: Assessment Checklist on Difficulty in Performing Adaptive Skills
No.  /x General Characteristics

1 Difficulty in dealing with other children
2 Acts as deaf
3 Resists learning
4 No fear of real dangers
5 Resists change in routine
6 Indicates need by gesture
7 Inappropriate laughing and giggling
8 Not cuddly
9 Marked physical over activity
10 No eye contact
11 Inappropriate attachments to objects
12 Spins objects
13 Sustained odd play
14 Standoffish manner
15 High pain tolerance
No.  /x Characteristics on Conceptual Skills
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1 Seems forgetful, easily distracted or daydreaming

2 Appears not to listen and has trouble following directions
3 Interrupts people, blurts things out inappropriately and may struggle with nonverbal cues
4 Acts without thinking and may not understand the consequences of his actions
5 Has obsessive interests and experiences perseveration
6 Disobey rules and policies
7 Fails to finish school works
8 Does not seem to listen when spoken to
9 Fall asleep easily in class
No.  /x Characteristics on Social Skills

1 Has trouble with safety and danger awareness
2 Has trouble showing understanding of other people’s feelings and his own
3 Has trouble showing understanding of other people’s feelings and his own
4 Uses excessive body movements to self-soothe (e.g., rocking, flapping hands)
5 Struggles with social skills
6 Has trouble waiting his turn and being patient
7 Struggles to sit still during quiet activities, such as mealtimes or during independent work -
time at school
8 Constantly “on the go” or moving; fidgets and needs to pick up and fiddle with everything
No.  /x Characteristics on Practical Skills

1 Struggles with organization and completing tasks
2 May overreact to sensory input, like the way things sound, smell, taste, look or feel
3 Gets upset by changes in routine
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4 Reacts strongly to the way things sound, smell, taste, look or feel (sensory processing issues)
5 Difficulty working independently in daily chores
6 Uses eating utensils inappropriately
7 Unable to put on shoes by himself
8 Unable to fold clothes
9 Difficulty in preparing simple meals
Screened by:
Date:
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COTABATO
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Form 7f: Assessment Checklist on Difficulty in Displaying

Interpersonal Behavior
No.  /x Characteristics
1 Bullies and threatens classmates and others
2 Initiates physical fights
3 Has little empathy for others and has lack of appropriate feelings of guilt
4 Lies to peers or teachers
5 Steals from peers or the school
6 Shows fearfulness and apprehension
7 Has difficulty in mingling/interacting with others
8 Has low self-esteem masked by showing boldness intended to impress or intimidate
9 Afraid of consequences of activities
10 Constantly seeks affirmation from others
11 Deliberately annoys others
12 Worries about things that might happen or have happened
13 Criticizes self and others
14 Avoids things or places or refuses to do things or go places
15 Expresses feelings of worthlessness, hopelessness
16 Blames self and others for one’s mistakes or misbehavior
17 Has lack of interest in classroom/school activities
18 Thinks or talks repeatedly of suicide
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19 Afraid of failure, rejection and embarrassment

20 Avoids work activities that involve contact with others
21 Avoids work activities that involve contact with others
22 Has the tendency to use and abuse prohibited drugs and alcohol
23 Defies and refuses to comply with rules and teacher’s requests
Screened by:
Date:
Form 7g: Speech and Language Characteristics

1 Usually has no speech
2 If he has speech, he…
 Uses limited vocabulary

 Speaks in words rather in sentences
 Is particularly poor in spelling
 Is poor in dictation
 Talks with poor rhythm
Sch
COTABATO
DISTRICT
SCHOOL
Screened by:
Date:
Form 8: Summary Report on the Multi-Factored Assessment (SRMFA)
Form 4 Form 5 Form 6 Form 7 Remarks

LSR LLS PSW AC
Legend:
Form 4: Learner’s Scholastic Ratings (LSR) and

Form 5: Least Learned Skills (LLS)
Form 6: Portfolio of School Work (PSW)
Form 7: Assessment Checklist for Teachers (ACT)
Sch
COTABATO
DISTRICT
SCHOOL
Prepared by:
Date:
Step 3: Curriculum Program Planning: Development of Educational Program (EP) or

Individualized Education Plan (IEP)
The formation gathered through multi-factored assessment forms the basis for planning a curriculum or
program that best corresponds to its current level of functioning. The educational program, which is an Individualized
Education Plan or IEP, is a written statement on the student's long-term and annual goals for the whole year, the
quarterly short-term objectives for each grading period, and the instructional plans for the months, weeks, and days in
each quarter or grading period. The IEP is used as the basis for planning the curriculum that best matches his or her
present level of functioning.
Sch
COTABATO
DISTRICT
SCHOOL
CONTEXTUALIZED
INDIVIDUALIZED
EDUCATION PLAN
Sch
COTABATO
DISTRICT
SCHOOL
Enclosure 4: Individualized Education Plan

INDIVIDUALIZED EDUCATION PLAN (IEP)
Overview – This IEP has been designed in accordance with the World Health Organization International
Classification of Functioning Disability and Health. In accordance with this approach Disability is defined
as an impairment in interaction with a wide range of environmental barriers. In this IEP, teachers are asked
to identify the learner’s impairment in combination with their school environment. The learning barriers
should be documented alongside accommodations designed to remove the participation barriers and improve
educational success.
SECTION A: PERSONAL INFORMATION
Learner: Sex:
Grade/Level:
Birth Date : LRN:
Current School :
Address of School :
Mother Tongue Spoken:
Address:
Contact Number (if there is)

Parent/Guardian/Caregiver:
Work & Workplace:

Landline/Mobile/Cell Phone No.
Facebook Account:
Mother Tongue Spoken:
Interpreter or Other Accommodations Needed:
Sch
COTABATO
DISTRICT
SCHOOL
DIFFICULTIES/DISABILITY
(Select most relevant)
Difficulty in Seeing/VI
Difficulty in Hearing/HI
Difficulty in Communicating/ComDis
Difficulty in Mobility Walking/PH
Difficulty in Displaying Interpersonal Behaviors EBD/ADHD
Difficulty in Performing Adaptive Skills/ASD
Difficulty in Basic Skills and Applying Knowledge/LD
Difficulty in Remembering /Concentrating/ID
Others (please specify)
Diagnosis (If yes, please specify)
Sch
COTABATO
DISTRICT
SCHOOL
MEETING INFORMATION
DATE OF MEETING:
DATE OF LAST IEP

PURPOSE OF MEETING:
Interim IEP**
Initial IEP
Term IEP
IEP Following 3-Yr Re-evaluation**
Revision to IEP Date
Exit/Graduation
IEP Revision Without a Meeting:
At the request of:
Sch
COTABATO
DISTRICT
SCHOOL
Parent
School
IEP Review Date:

COMMENTS:
IEP TEAM MEMBERS IN ATTENDANCE
Parent/Guardian/Caregiver
*Learner
Principal/School Head
Other (name and role)
Special Education Teacher
**Regular Education /Receiving Teacher
School Nurse:
Therapist/Pathologist/Specialist:
Speech/Language Interpreter
Other (name and role)
*Learner must be invited when transition is discussed.
**The IEP team must include at least one regular education teacher of the learner (if the learner is or may
be participating in the regular education environment)
==========================================================================
=================
Signature over Printed Name of Parent/Guardian/Caregiver
Sch
COTABATO
DISTRICT
SCHOOL
AT LEAST ONE YEAR PRIOR TO REACHING AGE 18, LEARNER MUST BE INFORMED OF
THEIR RIGHTS UNDER THE LAW AND ADVISED THAT THESE RIGHTS WILL BE ENJOYED AT
AGE 18.
Not Applicable (learner will not be 18 within one year

The learner has been informed of his/her rights under law and advised of the
transfer of
rights at age 18
Distribution: Learner’s Folder

Parent/Guardian/Caregiver/Education providers (Special
Education/Receiving Teacher)
LEARNER:
DATE :
I. PRESENT LEVELS OF ACADEMIC ACHIEVEMENT AND/OR FUNCTIONAL

PERFORMANCE
Results of initial or most recent evaluation and results of school and division assessments:
Description of academic, developmental and/or functional strengths:
Description of academic, developmental and/or functional needs:
Sch
COTABATO
DISTRICT
SCHOOL
Parental concerns regarding their child’s education:
Impact of the difficulty/disability on involvement and progress in the general education

curriculum (for preschool, how the difficulty/disability affects participation in appropriate
activities):
I. CONSIDERATION OF SPECIAL FACTORS

Does the learner have difficulty relating with people which impedes his/her learning or the learning of others?
 No  Yes
If yes, consider the appropriateness of developing a Behavior Intervention Plan.
Behavior Intervention Plan developed? 

No  Yes
Refer to Behavior Intervention Plan for additional information.
Does the learner have difficulty in Moving/Walking?
 No  Yes
If yes, consider the mobility needs as related to the IEP and describe below.
Does the learner have difficulty in seeing or with blindness/visual impairment?  No

 Yes
If yes, provide for instruction in Braille and the use of Braille, unless the IEP Team
determines that instruction in Braille is not appropriate for the learner after an evaluation
of the learner’s reading and writing skills, needs, and appropriate reading and writing media,
Sch
COTABATO
DISTRICT
SCHOOL
including evaluation of future needs for instruction in Braille or the use of Braille.
Describe below.
Does the learner have difficulty in communicating?

 No  Yes
If yes, consider the communication needs and describe below.
Does the learner have difficulty in concentrating/paying attention?

 No  Yes
If yes, consider the attention span needs and describe below.
Does the learner have difficulty in remembering/understanding?  No

 Yes
If yes, consider the understanding needs and describe below.
Does the learner have difficulty in hearing or Is the learner deaf or hard of hearing?  No
 Yes
If yes, consider and describe the learner’s language and communication needs, opportunities for direct communication
with peers and professional personnel in the learner’s language and communication mode, academic level and full range
of needs, including opportunities for direct instruction in the learner’s language and communication mode. Describe
communication needs below.
Does the learner need assistive technology devices or services?

 No  Yes
If yes, describe the type of assistive technology and how it is used. If no, describe how the learner’s needs are being met
in deficit areas.
Does the learner require alternative format for instructional materials?  No

 Yes
If yes, specify format(s) of materials required below.
 Braille  Large type  Auditory  Electronic text  Others (pls. specify)
Sch
COTABATO
DISTRICT
SCHOOL
SECTION B: DIFFICULTIES, BARRIERS AND ENABLING SUPPORTS
DIFFICULTY ENVIRONMENTAL ENVIRONMENTAL ACCOMMODATIONS

(enter all areas of BARRIERS (describe each FACILITATORS (describe (list items, staff resources
difficulty) factor restricting each factor enabling and infrastructure changes
participation) participation in response to required to enable
barriers) participation)
Sch
COTABATO
DISTRICT
SCHOOL
Selection of Barriers and Qualifiers for Environmental Barriers and

Facilitators (taken from ICF)
Legend:
.0 - none, absent, negligible (0-4%) .4 – total (96-100%)
.1 - slight, slow (5-24%) .8 – not specified
Sch
COTABATO
DISTRICT
SCHOOL
.2 – medium, fair (25-49%) .9 – not applicable

.3 – high, extreme (50-95%)
DIFFICULTIES (select all Qualifier for Qualifier for Environmental

relevant categories) Environmental Barriers Facilitators
o Seeing o .0 No barrier
o .1 Mild barrier
o +1 Mild facilitator
o +2 Moderate facilitator
o Hearing o .2 Moderate barrier o +3 Substantial facilitator
o Communicating o .3 Severe barriers o +4 Complete facilitator
o .4 Complete o +8 Facilitator, not specified
o Moving/Walking barriers o +9 Not applicable
o Concentrating/Paying o .8 Barrier, not
Attention specified
o Remembering/Understanding o .9 Not applicable
SECTION C: LEARNER GOALS
To support identification of learner goals, also confirm:

o What opportunities are available at the school to support learner goals?
o What are the student interest areas?
o What disability-specific skills does the learner need to develop to support their participation /
attainment of goals?
Goals (eg – Skills to improve participation in education or daily living skills. Goals should be SMART
(Strategic, Measurable, Achievable, Realistic and Time-bound)
INTEREST GOAL INTERVEN- TIMELINE INDIVIDUALS REMARKS PROGRESS /

TIONS RESPONSIBLE NEXT STEPS
Sch
COTABATO
DISTRICT
SCHOOL
SECTION D: LEARNER TRANSITION
This section is for learners exiting the school environment and transitioning into work.
INTEREST WORK INTERVENTIONS / INDIVIDUALS REMARKS

OPPORTUNITIES TRANSITION RESPONSIBLE
SKILLS
Sch
COTABATO
DISTRICT
SCHOOL
Prepared by: Noted by:
Your Name School

Principal
Step 4: Placement in Appropriate SPED Program
Sch
COTABATO
DISTRICT
SCHOOL
The learner is placed in a SPED program that can provide the least restrictive environment. The array of
SPED programs includes inclusive education, special and residential schools, homebound or hospital-bound
teaching, and variations or combinations of services.
Step 5: Review and Evaluation

Evaluation is a built-in component of each step-in planning and implementing a SPED program. A
review and a formative evaluation of each step's results are done to ensure the correct implementation of the
SPED cycle.
Sch
COTABATO
DISTRICT
SCHOOL
Sch

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Republic of the Philippines

(Screening, Evaluation,and Assessment

For the Teachers:

INDIVIDUAL LEARNER’S PROFILE

Name: Date of Birth: Age:

Type of Learner: LRN:

Interview with Parents/Guardian

Interview with the Learner

DAILY LIVING SKILLS DOMAIN: Present Level of Educational Performance

LANGUAGE DEVELOPMENT DOMAIN: Present Level of Educational Performance

PSYCHOMOTOR DOMAIN: Present Level of Educational Performance

COGNITIVE DOMAIN: Present Level of Educational Performance

AESTHETIC AND CREATIVE DOMAIN: Present Level of Educational Performance

BEHAVIORAL DEVELOPMENT: Present Level of Educational Performance

ORIENTATION AND MOBILITY: Present Level of Educational Performance

Step 1: Pre-referral Intervention/Initial Screening

Form 1: Teacher Nomination (TN)

Name Grade Age Teacher

Teacher’s Name & Signature

Form 2a: Checklist in Learning and Behavior Characteristics

2. Cannot spell correctly at grade level

3. Cannot write from dictation at grade level

4. Reverses letters or entire words

2. Cannot stay on line

3. Cannot copy simple sentences from

2. Loses place when reading

3. Repeats, omits or adds words

4. Cannot read the DOLCH words

5. Uses fingers to follow lines

6. Cannot understand/remember what he/she

4. Fails to comprehend math concepts

5. Get confused with written and/or oral

2. Cannot follow oral direction

3. Has articulation problem; wrong

3. Lacks rhythm in movement, loses

Scoring and Interpretation of Results

75-105 points = Manifest almost all of the learning disability characteristics

50-74 points = Manifest most all of the learning disability characteristics

35-below points= Manifest some of the learning disability characteristics

Signature over printed name

Form 2b: Summary Report on Pre-Referral Screening

Name Grade Level Age Score Remarks

Signature over printed name

Form 2c: Individual Report on Pre-Referral Screening

Initial Screening Score: Interpretation:

Recommended for multi-factored assessment: Yes No

Signature over printed name

Form 3: Child’s Profile: Case History Record (CHR)

Father’s Name: Age:

Birthday: Birthplace: Citizenship:

Mother’s Name: Age:

 Academic Difficulty (please specify):

Age of mother at child’s birth: Age of father at child’s birth:

Did the infant have jaundice, convulsions, blood incompatibility, etc.? (

Condition Age Description

Describe any accidents or operations including dates:

Has the child any serious reactions to immunization?