Examiner’s Note
Department of Education
Name of Examiner: ___________________________
Date Administered: ___________________________
Place of test: _________________________________
Child’s background (ex. Behavior/health/etc.)
______________________________________________
______________________________________________
______________________________________________
______________________________________________
______________________________________________
Family environment (ex. Health of family
members/family problems/economic
conditions/etc.)
______________________________________________
______________________________________________
______________________________________________
______________________________________________
______________________________________________
Parent’s stimulating activities for the child (what
are the activities/things that the parents do to
help stimulate the child’s development)
______________________________________________
______________________________________________
______________________________________________
______________________________________________
______________________________________________
Home environment (ex. Facilities/type of house/
household items/interaction/etc.)
______________________________________________
______________________________________________
______________________________________________
______________________________________________
______________________________________________
Others:
______________________________________________
______________________________________________
______________________________________________
______________________________________________
______________________________________________
Republic of the Philippines
Region V-Bicol
Name of Examiner: ___________________________
Date Administered: ___________________________
Schools Division Office
Place of test: _________________________________ Camarines Norte
Mercedes District
Child’s background (ex. Behavior/health/etc.) __________________ ELEMENTARY SCHOOL
______________________________________________
______________________________________________
______________________________________________ PHILIPPINE EARLY CHILDHOOD DEVELOPMENT CHECKLIST
______________________________________________ Child’s Record Form 2
______________________________________________
Family environment (ex. Health of family Child’s Name: _______________________________________ Sex: __________
members/family problems/economic
conditions/etc.) Address: _________________________________________ Date of Birth: ______________
______________________________________________
______________________________________________
______________________________________________
Child’s Handedness (Check appropriate box)
______________________________________________ Right Left Both Not Yet Established
______________________________________________
Is the child presently studying? (Check appropriate box) Yes No
Parent’s stimulating activities for the child (what
are the activities/things that the parents do to
help stimulate the child’s development) Father’s Name: ______________________________________________________________
______________________________________________
______________________________________________ Father’s Age: ________________________________________________________________
______________________________________________
______________________________________________
Father’s Occupation: __________________________________________________________
______________________________________________
Home environment (ex. Facilities/type of house/ Father’s Educational Attainment: ________________________________________________
household items/interaction/etc.)
______________________________________________ Mother’s Name: ____________________________________________ _______ _________
______________________________________________
______________________________________________
______________________________________________ Mother’s Age: _______________________________________________________________
______________________________________________
Mother’s Occupation: _________________________________________________________
Others:
______________________________________________
______________________________________________ Mother’s Educational Attainment: _______________________________________________
______________________________________________
______________________________________________ Child’s Number of Siblings: _____________________________________________________
______________________________________________
Child’s Birth Order (1st, 2nd, 3rd, etc) ___ _________________________________________
 GROSS MOTOR DOMAIN BOSY MID YEAR EOSY SOCIAL EMOTIONAL DOMAIN BOSY MID YEAR EOSY
Assessment Assessment Assessment Assessment Assessment Assessment
P O R P O R P O R P O R P O R
1. Climbs on chair or other elevated piece of furniture 23. Watches responsibility over younger siblings/family
like a bed without help members
2. Walks backwards runs without tripping or falling 24. Cooperates with adults and peers in group situations
3. Walks downstairs, 2 feet on each step, with one to minimize quarrels and conflicts
hand held TOTAL SCORE
4. Walks upstairs holding handrail, 2 feet on each step
5. Walks upstairs with alternate feet without holding BOSY ASSESSMENT MID YEAR ASSESSMENT EOSY ASSESSMENT
handrail DOMAIN
Date _______________ Date _______________ Date _______________
6. Walks downstairs with alternate feet without Child’s Age __________ Child’s Age___________ Child’s Age __________
holding handrail Raw Scaled Raw Scaled Raw Scaled
7. Moves body part as directed Score Score Score Score Score Score
8. Jumps up Gross Motor
9. Throws ball overhead with direction Fine Motor
10. Hops 3 steps on preferred foot Self – Help
11. Jumps and Turns Receptive Language
12. Dances patterns/ joins group movement activities Expressive Language
TOTAL SCORE Cognitive
Social – Emotional
FINE MOTOR DOMAIN BOSY MID YEAR EOSY
Assessment Assessment Assessment
Sum of Scaled Scores
P O R P O R P O R Standard Score
1. Uses all 5 fingers to get food/toys placed on a flat Date Tested
surface
2. Picks up objects with thumb and index finger Scaled Score Interpretation Standard Score Interpretation
3. Displays a definite hand preference Development in the domain must be Overall development must be
1-3 69 and below
4. Puts small objects in/out of containers monitored after 3 months monitored after 3 months
5. Holds crayon with all the fingers of his hand as Development in the domain must be Overall development must be
4-6 70 - 79
though making a fist (i.e., palmar grasp) monitored after 6 months monitored after 6 months
6. Unscrews lid of container or unwraps food Average overall development in the Average overall development in the
7 - 13 80 - 119
7. Scribbles spontaneously domain domain
8. Scribbles vertical and horizontal line
14 - 16 Suggest slightly advanced 120 - 129 Suggest slightly advanced
9. Draws a human figure (head, eyes, trunk, arms, development in the domain development in the domain
hands/fingers)
17 - 19 Suggest highly advanced 130 and above Highly advanced overall development
10. Draws a house using geometric forms development in the domain
TOTAL SCORE
6
1
 SOCIAL – EMOTIONAL DOMAIN BOSY MID YEAR EOSY SELF – HELP DOMAIN BOSY MID YEAR EOSY
Assessment Assessment Assessment Assessment Assessment Assessment
P O R P O R P O R P O R P O R P O R
1. Enjoys watching activities of nearby people or Feeding Sub - Domain
animals 1. Feeds self with finger foods (e.g., biscuits, bread)
2. Friendly with strangers but initially may show slight using finger
anxiety or shyness 2. Feeds self using fingers to eat rice/viands with
3. Plays alone but likes to be near familiar adults or spillage
brothers and sisters 3. Feeds self using spoon with spillage
4. Laughs or squeals aloud in play 4. Feeds self using fingers without spillage
5. Plays peek – a – boo (bulaga) 5. Feeds self using spoon without spillage
6. Rolls ball interactively with caregiver/examiner 6. Eats without need for spoon feeding during any meal
7. Hugs or cuddle toys 7. Helps hold cup for drinking
8. Demonstrates respect for elders using terms like 8. Drinks from cup with spillage
“po” and “opo” 9. Drinks from cup unassisted
9. Shares toys with others 10. Pours from pitcher without spillage
10. Imitates adult activities (e.g., cooking, washing) 11. Prepares own food/snack
11. Identifies feelings in others 12. Prepares meals for younger siblings/family members
12. Appropriately uses cultural gestures of greeting when no adult is around
without much prompting (e.g., mano, bless, kiss, Dressing Sub – Domain
etc.) 13. Participates when being dressed (e.g. raises arms or
13. Comforts playmates/siblings in distress lifts leg)
14. Persists when faced with a problem or obstacle to 14. Pulls down gartered short pants
his wants 15. Removes sando
15. Helps with family chores (e.g., wiping tables, 16. Dresses without assistance except for buttoning and
watering plants, etc.) tying
16. Curious about environment but knows when to stop 17. Dresses without assistance, including buttoning and
asking questions of adults tying
17. Waits for his/her turn Toilet training – sub domain
18. Asks permission to play with toy being used by 18. Informs the adult only after he has already urinated
another (peed) or moved his bowels (poohed) in his
19. Defends possessions with determination underpants
20. Plays organized group games fairly (e.g., does not 19. Informs adult of need to urinate (pee) or move
cheat in order to win) bowels (pooh – pooh) so he can be brought to a
21. Can talk about complex feelings (e.g., anger, designated place (e.g., comfort room)
sadness, worry) he experiences 20. Goes to the designated place to urinate (pee) or
22. Honors a simple bargain with caregiver (e.g., plays move bowels (pooh) but sometimes still does this in
outside only after cleaning/fixing his room) his underpants
5 2
 SELF – HELP DOMAIN BOSY MID YEAR EOSY EXPRESSIVE LANGUAGE DOMAIN BOSY MID YEAR EOSY
Assessment Assessment Assessment Assessment Assessment Assessment
P O R P O R P O R P O R P O R P O R
21. Goes to the designated place to urinate (pee) or 6. Asks “what” questions
move bowels (pooh) and never does this in his 7. Asks “who” and “why” questions
underpants anymore 8. Gives account of recent experiences (with prompting)
22. Wipes/cleans self after a bowel movement (pooh) in order of occurrence using past tense
Bathing sub – domain
23. Participates when bathing (e.g. rubbing arms with COGNITIVE DOMAIN BOSY MID YEAR EOSY
Assessment Assessment Assessment
soap)
P O R P O R
24. Washes and dries hands without any help
1. Looks at direction of a fallen object
25. Washes face without any help
2. Looks for a partially hidden object
26. Bathes without any help
3. Imitates behavior just seen a few minutes earlier
TOTAL SCORE
4. Offers on object but may not release it
5. Looks for completely hidden object
RECEPTIVE LANGUAGE DOMAIN BOSY MID YEAR EOSY 6. Exhibits simple “pretend” play (feeds, puts doll to
Assessment Assessment Assessment
sleep)
P O R P O R P O R
7. Matches objects
1. Points to family member when asked to do so
8. Matches 2 to 3 colors
2. Points to 5 body parts on himself when asked to do
9. Matches pictures
so
10. Sorts based on shapes
3. Points to 5 named pictured objects when asked to
11. Sorts objects based on 2 attributes (e.g., size and
do so
color)
4. Follows one – step instructions that include simple
12. Arranges objects according to size from smallest to
prepositions (e.g., in, on, under, etc.)
biggest
5. Follows 2 – step instructions that include simple
13. Names 4 to 6 colors
prepositions
14. Copies shapes
TOTAL SCORE
15. Names 3 animals or vegetables when asked
EXPRESSIVE LANGUAGE DOMAIN BOSY MID YEAR EOSY 16. States what common household items are used for
Assessment Assessment Assessment 17. Can assemble simple puzzles
P O R P O R P O R 18. Demonstrates an understanding of opposites by
1. Uses 5 – 20 recognizable words completing a statement (e.g., “Ang aso ay malaki, ang
2. Uses pronouns (e.g. I, me, ako, akin) daga ay ____________)
3. Uses 2 – to 3 – word verb – noun combinations (e.g. 19. Points to left and right sides of body
hingi gatas) 20. Can state what is silly or wrong with pictures (e.g. Ano
4. Names objects in pictures ang mali sa larawang ito?)
5. Speaks in grammatically correct 2 – to 3 – word 21. Matches upper and lower case letters
sentences TOTAL SCORES
3 4