GROSS MOTOR DOMAIN 1 2 FINE MOTOR DOMAIN 1 2 1 2 SELF- HELP DOMAIN 1 2

SELF- HELP DOMAIN

REPUBLIC OF THE PHILIPPINES 1 Climbs on chair or 1 To get food/toys. 1 Feeds self with 14 Participates when being
Department of Education other elevated piece
finger foods (e.g. dressed (e.g. raises
Region X-Northern Mindanao of furniture like a bed 2 Picks up objects
biscuits, bread) arms.lefts leg)
Division of Lanao del Norte without help. with thumb and
using fingers.
index finger. 15 Pulls down gartered
2 Walks backward. 2 Feeds self, using
3 Displays a definite short pants
CAMP 3 ELEMENTARY SCHOOL spoon without
3 Runs without tripping hand preference. 16 Removes sando
School Year: 2017-2018 spillage.
or falling
4 Puts small objects 3 Feeds self, using
17 Dresses without
spoon wit spillage.
PHILIPPINE EARLY CHILDHOOD 4 Walks down stairs, 2 in/out of assistance except for
DEVELOPMENT CHECKLIST feet on each step, with containers buttons and tying
4 Feeds self, using
one hand held 5 Holds crayon with 18 Dresses without
(FORM 2) all five fingers (i.e .
fingers without
spillage. assistance including
palmar grasp) butons and tying
5 Walks upstairs holding 5 Feeds self, using
Name: _______________________ 19 Informs tha adult only
handrail, 2 feet on fingers without
each feet 6 Lid of container or spillage. after he has already
LRN #: ________________________ unwraps food urinated or moved his
6 Eats without need
for spoon feeding bowels in his underpants
SEX: _____________ 6 Walks upstairs with
20 Informs adult of need to
alternate feet without during any meal
urinate or move bowels
Date of Birth: __________________ holding handrail 7 Scribbles
so he can be brought to
spontaneously. 7 Helps hold cup for
drinking. a designated place (e.g
Preferred Hand:______Right _____left 7 Walks downstairs with CR)
alternate feet without 8 Drinks from cup 21 Goes to the designated
holding the handrail 8 Scribbles vertical with spillage. place to urinate or move
Date of Child’s and horizontal
Examination bowels but sometimes
Examination Age lines 9 Drinks from cup still does this in his
8 Moves body part as
First Exam 9 Draws circle unassisted. underpants.
directed
Second purposely. 22 Goes to the designated
10 Draws a human 10 Gets drink for self place to urinate or move
Exam 9 Jumpsup.
figure ( head, eyes, unassisted. bowels and never does
trunk, arms, this in his underpants
Prepared by: 10 Throws ball overhead
hands/finger) 11 Pours from pitcher 23 Wipes/clean self after a
with direction
without spillage. bowel movement.
NENA LYN A. MAGHANOY 11 Hops 1 to 3 steps on 24 Participates when
11 Draws a house 12 Prepares own bathing (e.g.rubbing
Kindergarten Teacher preferred foot
using geometric food/snacks. arms with soap).
forms.
12 Jumps and turns. 25 Washes and dries hand
Noted: 13 Prepares meals for without any help.
younger
Washes

DIOSCORA P. CAGOD 13 Dances patterns/joins 26 Washes face without any

group movement siblings/family help
School Head activities. members when no
adult is around. 27 Bathes without any help.

TOTAL SCORE: TOTAL SCORE: TOTAL SCORE:

 COGNITIVE DOMAIN 1 2 SOCIO – EMOTIONAL 1 2 17 Curious about
RECEPTIVE LANGUAGE 1 2 1 Looks at direction of DOMAIN environment but knows INTERPRETATION:
DOMAIN fallen objects. 1 Enjoys watching when to stop asking
1 Points to a family member 2 Looks for hidden activities of nearby questions of adults.
people or animals. 18 Waits for turn. 1ST Examination:
when asked to do so. objects.
3 Imitates behavior just 2 Friendly with strangers 19 Defend possessions with __________________________
2 Points to 5 body parts on
seen a few minutes but initially may show determination. __________________________
himself when asked to do slight anxiety or shyness. 20
earlier. Plays organized group __________________________
so. 3 Plays alone but likes to games fairly. (e.g. does
4 Offers objects but will ND
2 Examination:
3 Points to 5 named picture be near familiar adults or
not release it. not cheat in order to
brothers and sisters. __________________________
objects when asked to do 5 Looks for completely win)
4 Laughs or squeals
so. hidden objects 21 Can talk about difficult __________________________
aloud in play.
4 Follows one- step 6 Exhibits simple 5 Plays peek-a-boo
feelings (e.g. anger, __________________________
instruction that include pretend play sadness, worry)he
(bulaga)
simple prepositions 7 Matches objects. 6 Rolls ball interactively
experiences. LEGEND
8 22 Honors a simple bargain STANDARD INTERPRETATION
(e.g.in,on,under) Matches 2-3 colors. with caregiver.
with caregiver (e.g. can
5 Follows 2-step instructions 9 Matches pictures. examiner. SCORE
10 7
play outside only after
that include simple Sorts based on shapes. Hugs or cuddles toys. 69 and Suggest significant delay in
cleaning/finishing this
prepositions. 11 Sorts objects based on 8 Demonstrates respect for
elders using terms like room. below overall development.
2 attributes. 23
TOTAL SCORE: 12 Arranges objects “po” and “opo”. Watches responsibility 70-79 Suggest slight delay in
according to size from 9 Shares toys with over younger overall development.
smallest to the biggest. others siblings/family members.
EXPRESSIVE LANGUAGE 1 2 24 Cooperates with adults
80-119 Average development
13 Names 4-6 colors. 10 Imitates adult
DOMAIN activities (e.g cooking, and peers in group 120-129 Suggest slightly advanced
Uses 5-20 recognizable 14 Copies shapes. situations to minimize development.
1 washing)
words. 15 Names 3 animals or 11 Identifies feelings in quarrels and conflicts. 130 and Suggest highly advanced
2 Uses pronouns vegetables when others. TOTAL SCORE: above development.
asked. 12 Appropriately uses
3 Uses 2-3 verb- noun
16 States what common cultural gestures of
combinations (hinngi greeting without much RAW SCORE SCALED SCORE
household items are
gatas) used prompting. DOMAIN 1st 2nd 1st 2nd
4 Names objects in pictures. 17 Can assemble simple 13 Comforts
Speaks grammatically playmates/siblings in GROSS
5 puzzles
Demonstrates an distress. FINE
correct 2-3 word 18
understanding of 14 Persist when faced
sentences. with a problem or SELF – HELP
opposites by completing
6 Ask “what” questions. a statement. obstacles to his wants. RECEPTIVE
7 Asks “who” and “why” 19 Points to left and right 15 Helps with family chores EXPRESSIVE
questions. sides of body (e.g. wiping tables,
watering plants etc.)
COGNITIVE
8 Gives account of recent 20 Can state what is silly
or wrong with 16 Asks permission to SOCIO –
experiences (with prompting
in order of concurrence using pictures. play with toy being EMOTIONAL
21 Matches upper and used by another.
past tense. SUM OF SCALED
lower case letters. SCORE
TOTAL SCORE: TOTAL SCORE: STANDARD SCORE