Gross Motor Domain 7 Scribbles spontaneously.

√ √ urinated (peed) or moved his bowels (pooped) in

his underpants.
Gross Motor Beginning Ending 8 Scribbles vertical and horizontal lines. √ √
Informs adult of need to urinate (pee) or move
Climbs on chair or elevated piece of furniture 9 Draws circle purposely. √ √ 20 bowels (poop) so he can be brought to a √ -
1 √ √
designated place (e.g. comfort room)
like a bed without help.
Draws a human figure (head, eyes, trunk,
10 √ √
2 Walks backwards √ √ arms, hands/fingers) Goes to the designated place to urinate (pee) or
21 move bowels (poop) but sometimes still does this - -
11 Draws a house using geometric forms. - √ in his underpants.
3 Runs without tripping or falling. √ √

Walks down stairs, 2 feet on each step, with TOTAL SCORES 10 11 Goes to the designated place to urinate (pee) or
4 √ √ 22 move bowels (poop) and never does this in his - √
one hand held.
underpants anymore
Walks upstairs holding handrail, 2 feet on Self - Help Domain
5 √ √ 23 Wipes/Cleans self after a bowel movement (poop) √ √
each step.
Self-Help Beginning Ending
Walks upstairs with alternate feet without Participates when bathing (e.g. rubbing arms with
6 √ √ Feeds self with finger foods (e.g. biscuits, bread) 24 - √
holding handrail. 1 √ √ soap)
using fingers.
Walks downstairs with alternate feet without 25 Washes and dries hands without any help √ √
7 √ √ 2 Feeds self using fingers with spillage. √ √
holding handrail.
26 Washes face without any help √ √
3 Feeds self using spoon with spillage. √ √
8 Moves body part as directed. √ √
27 Bathes without any help √ √
4 Feeds self using fingers without spillage. - √
9 Jumps up √ √
TOTAL SCORE 19 23
5 Feeds self using spoon without spillage. - √
10 Throws ball overhead with direction. √ √
Eats without need for spoon feeding during any
6 √ √
11 Hops 1 to 3 steps on preferred foot. √ √ meal. Receptive Language Domain
12 Jumps and turns. √ √ 7 Helps hold cup for drinking. √ √ Receptive Language Beginning Ending

Dances patterns/joins group movement 8 Drinks from cup with spillage. √ √ 1 Points to family member when asked to do so √ √
13 √ √
activities.
9 Drinks from cup unassisted. √ √ Points to 5 body parts on himself when asked
2 √ √
TOTAL SCORE 13 13 to do so
10 Gets drink for self unassisted. √ √
Points to 5 named pictured objects when
3 √ √
11 Pours from pitcher without spillage. √ √ asked to do so

Fine Motor Domain 12 Prepares own food/snack. - √

4
Follows one-step instructions that include
√ √
simple prepositions (e.g., in, on, under, etc.)
Fine Motor Beginning Ending Prepares meals for younger siblings/ family
13 - -
members when no adult is around. Follows 2-step instructions that include simple
5 √ √
Uses all five fingers to get food/toys placed prepositions
1 √ √ 14 Participates when being dressed. √ √
on flat surface.
TOTAL SCORE 5 5
2 Picks up objects with thumb and index finger. √ √ 15 Pulls down gartered short pants. √ √

3 Displays a definite hand preference. √ √ 16 Removes sando. √ √

Expressive Language Domain
4 Puts small objects in/out of containers. √ √ Dresses without assistance except buttons and
17 √ √ Expressive Language Beginning Ending
tying.
Holds crayon with all fingers of his hand
5 √ √ Dresses without assistance including buttons and 1 Uses 5-20 recognizable words √ √
making a fist(ex.palmar grasp) 18 √ √
tying.
2 Uses pronouns (e.g. I, me, ako, akin) √ √
6 Unscrews lid of container or unwraps food. √ √
19 Informs the adult only after he has already - -
3 Uses 2-3 words verb-noun combinations (e.g. √ √
 hingi gatas) asked obstacle to his wants

4 Names objects in pictures √ √ States what common household items are Social-Emotional Beginning Ending
16 √ √
used for
Speaks in grammatically correct 2-3 word Helps with family chores (e.g., wiping tables,
5 √ √ 15 √ √
sentences 17 Can assemble simple puzzles - √ watering plants, etc.)
6 Asks “what” questions √ √ Demonstrates an understanding of Curious about environment but knows when
18 opposites by completing a statement (e.g., √ √ 16 √ √
to stop asking questions from adults
7 Asks “who”' and “why” questions √ √ Ang aso ay malaki, ang daga ay _____”)
17 Waits for turn √ √
Gives account of recent experiences (with 19 Points to left and right sides of body √ √
8 prompting) in order of occurrence using past √ √ Asks permission to play with toy being used
tense Can state what is silly or wrong with 18 √ √
by another
20 pictures (e.g. Ano ang mali sa larawang √ √
TOTAL SCORE 8 8 ito?) 19 Defends possessions with determination √ √

21 Matches upper and lower case letters - √ Plays organized group games fairly (e.g.,
20 √ √
does not cheat in order to win)
TOTAL SCORE 19 21
Can talk about difficult feelings (e.g., anger,
Cognitive Domain 21 √ √
sadness, worry) he experiences.
Cognitive Beginning Ending Socio-Emotional Domain
Honors a simple bargain with caregiver (e.g.,
Social-Emotional Beginning Ending 22 can play outside only after cleaning/fixing his √ √
1 Looks at direction of fallen object √ √
room)
Enjoys watching activities of nearby people or
2 Looks for partially hidden object √ √ 1 √ √
animals Watches responsibly over younger
23 - √
Imitates behavior just seen a few minutes siblings/family members
3 √ √ Friendly with strangers but initially may show
earlier 2 √ √
slight anxiety or shyness Cooperates with adults and peers in group
24 √ √
4 Offers object but will not release it √ √ situations to minimize quarrels and conflicts
Plays alone but likes to be near familiar adults
3 √ √
5 Looks for completely hidden object √ √ or brothers and sisters TOTAL SCORE 23 24
Exhibits simple pretend play (feed, put doll to 4 Laughs or squeals aloud in play √ √
6 √ √
sleep)
5 Plays peek-a-boo (bulaga) √ √ Beginning Date:_8/25/22____ Ending Date:_6/15/23_______

7 Matches objects √ √
6 Rolls ball interactively with caregiver/examiner √ √ DOMAINS Raw Scaled Raw Scaled
8 Matches 2 – 3 colors √ √ Score Score Score Score
7 Hugs or cuddles toys √ √
Cognitive Beginning Ending Demonstrates respect for elders using terms Gross Motor 13 11 13 11
8 √ √
like “po” and “opo”
9 Matches pictures √ √
Fine Motor 10 10 11 12
9 Shares toys with others √ √
10 Sorts based on shapes √ √
Self-help 19 2 23 7
Imitates adult activities (e.g., cooking,
Sorts objects based on 2 attributes (e.g., 10 √ √
11 √ √ washing)
size and color) Receptive Language 5 11 5 11
11 Identifies feelings in others √ √
Arranges objects according to size from Expressive Language 8 11 8 11
12 √ √
smallest to biggest Appropriately uses cultural gestures of
12 greeting without much prompting (e.g., mano, √ √ Cognitive 19 11 21 13
13 Names 4 – 6 colors √ √ bless, kiss,etc.)
14 Copies shapes √ √ Socio-Emotional 23 11 24 13
13 Comforts playmates/siblings in distress √ √

15 Names 3 animals or vegetables when √ √ 14 Persists when faced with a problem or √ √

 Sum of Scaled Score 67 78 Teacher: REYCIL M. PETALCORIN______________

Standard Score 82 91
To the Parents: The Philippine Early Childhood Care and
Average Overall Average Overall Development Checklist (Form 2) contain knowledge, skills,
Interpretation
Development Development and attitudes of children 3 – 5.11 years old. This may be
used as a guide in knowing your child and consequently
give appropriate care and teaching to guide their growth
REYCIL M. PETALCORIN RAMIL M. GEMOTA and development.
Adviser School Head

Republic of the Philippines

Department of Education
Region VII, Central Visayas
Division of Carcar City

School: KALANGYAWON ELEM.

School Year: 2022-2023

LRN: __119711220010________________________
Name: _CERPENTERO, JIMZ CLYNT A.__________
Sex: __MALE Date of Birth: _MAY 08, 2017________