Child’s Name: ______________________________

SOCIO- EMOTIONAL BoSY EoSY

Sex: _________ Date of Birth: _________________
DOMAIN
P O R P O R Address: __________________________________ Municipality of General Mariano Alvarez
San Gabriel II Elementary School
1
Enjoys watching activities of people or nearby Child’s Handedness: (Check Appropriate Box) S.Y. 2019-2020
animals.
Right Left Not yet established
Friendly w/ strangers but may initially show slight
2
shyness.
Father’s Name: ______________________________
Plays alone but likes to be near to familiar adults or
3
brother and sister. Occupation: ________________________________
4 Laughs or squeals aloud in play. Educational Attainment: _______________________ Early Childhood Care and
5 Plays peek-a-boo (bulaga). Mother’s Name: _____________________________ Development (ECCD)
6 Rolls ball interactively with caregiver/ examiner.
Occupation: ________________________________
Educational Attainment: _______________________
7 Hugs or cuddles toys.

8
Demonstrates respect for elders using “po” and SUMMARY OF ASSESSMENT Checklist
“opo”.
Shares toys with others familiar adults or brother and
9
sister.
BoSY EoSY
10 Imitates adults activities (e.g. cooking, washing) Date Assessed
Pupil’s Age
11 Identifies feelings of others. Domains RS SC RS SC

Appropriately uses cultural gestures of greetings Gross-Motor

12
without much prompting( e.g. mano/bless, kiss, etc.) Fine Motor
13 Comforts playmates/siblings in distress. Self-Help
Name: _________________________________
Receptive Language
Persists when faced with a problem or obstacle to his Sex: __________________
14 Expressive Language
wants.
Cognitive Birthday: _________________
Helps with family chores(e.g. wiping tables, watering
15
plants) Socio-emotional
LRN: -
Curious about environment but knows when to stop Sum of Scaled Scores
16
asking questions to adult.
Standard Scores
RS – Raw Score
17 Waits for turns. SC – Scaled Score To the Parents:
Asks permission to play with toys being used by The Philippine Early Childhood Care and Development Checklist
18 (Form 2) contains knowledge, skills, and attitudes of children 3 – 5.11 years
others.
old. This may be used as a guide in knowing your child and consequently give
BoSY: appropriate care and teaching to guide their growth and development.
19 Defends possessions with determination.
INTERPRETATION
Plays organized group games fairly(e.g. does not
20
cheat in order to win).

21
Can talk about difficult feelings (e.g. anger, sadness, PARENT’S SIGNATURE __________________
worry) he experience.
DAISY M.ABENOJAR
Honors a simple bargain with caregiver (e.g., can Teacher
22
play outside only after cleaning/fixing his room)
___________________________
23
Watches responsibly over younger siblings/family EoSY: FLORPINA B. GALAY
members. Principal IV
INTERPRETATION
Cooperates with adults and peers in group situations
24
to minimize quarrels and conflicts.

Total Raw Score PARENT’S SIGNATURE GROSS MOTOR DOMAIN BoSY EoSY
P O R P O R
1 Climbs on chair or elevated piece of furniture like a
PUPIL’S SOCIO-DEMOGRAPHIC PROFILE
 bed without help 7 Helps hold cup for drinking. 1 Uses 5-20 recognizable words
2 Walks backward. 8 Drinks from cup with spillage. 2 Uses pronouns (e.g. I, me, ako, akin)
3 Runs without tripping or falling. 3 Uses 2-3 words verb-noun combinations (e.g. hingi
9 Drinks from cup unassisted.
gatas)
4 Walks down stairs, 2 feet on each step, with one 10 Gets drink for self unassisted. 4 Names objects in pictures
hand held.
Walks upstairs holding handrail, 2 feet on each step. 11 Pours from pitcher without spillage. 5 Speaks in grammatically correct 2-3 word sentences
5
12 Prepares own food/snacks. 6 Asks “what” questions
6 Walks upstairs with alternate feet without holding
7 Asks “who”' and “why” questions
handrail. 13 Prepares meals for younger siblings/ family members
Walks downstairs with alternate feet without holding when no adult is around. 8 Gives account of recent experiences (with prompting)
7 in order of occurrence using past tense
handrail. 14 Participates when being dressed.
Moves body part as directed. Total Raw Score
8 15 Pulls down gartered short pants.
9 Jumps up Removes sando.
16
1 Throws ball overhead with direction. Dresses without assistance except buttons and tying.
17
0 Dresses without assistance including buttons and tying.
18
1 Hops 1 to 3 steps on preferred foot.
Informs the adult only after he has already urinated
1 19 (peed) or moved his bowels (pooped) in his
1 Jumps and turns. COGNITIVE DOMAIN BoSY EoSY
underpants.
2 Informs adult of need to urinate (pee) or move bowels P O R P O R
Dances patterns/joins group movement activities. 20 (poop) so he can be brought to a designated place 1 Looks at direction of fallen object
1
(e.g. comfort room) 2 Looks for partially hidden object
3
Goes to the designated place to urinate (pee) or move 3 Imitates behavior just seen a few minutes earlier
Total Raw Score 21 bowels (poop) but sometimes still does this in his
underpants. 4 Offers object but will not release it
Goes to the designated place to urinate (pee) or move 5 Looks for completely hidden object
22 bowels (poop) and never does this in his underpants 6 Exhibits simple pretend play (feed, put doll to sleep)
anymore
Wipes/Cleans self after a bowel movement (poop) 7 Matches objects
23
8 Matches 2 – 3 colors
BoSY EoSY 24
Participates when bathing (e.g. rubbing arms with
FINE MOTOR DOMAIN soap) 9 Matches pictures
P O R P O R
25 Washes and dries hands without any help.
Uses all five fingers to get food/toys placed on flat surface. 10 Sorts objects based on 2 attributes (e.g., size and
1 Washes face without any help.
26 color)
2 Picks up objects with thumb and index finger. 11 Sorts objects based on 2 attributes (e.g.,shape and
27 Bathes without any help.
Displays a definite hand preference. color)
3
Total Raw Score 12 Arranges objects according to size from smallest to
Puts small objects in/out of containers.
4 biggest
Holds crayon with all fingers of his hand making a fist (i.e. 13 Names 4 – 6 colors
5 palmar grasp)
14 Copies shapes
6 Unscrews lid of container or unwraps food.
7 Scribbles spontaneously. 15 Names 3 animals or vegetables when asked
8 Scribbles vertical and horizontal lines. 16 States what common household items are used for
9 Draws circle purposely. BoSY EoSY 17 Can assemble simple puzzles
10
Draws a human figure (head, eyes, trunk, arms, RECEPTIVE LANGUAGE P O R P O R 18 Demonstrates an understanding of opposites by
hands/fingers)
Draws a house using geometric forms. 1 Points to family member when asked to do so completing a statement (e.g., Ang aso ay malaki, ang
11
2 Points to 5 body parts on himself when asked to do so daga ay _____”)
Total Raw Score 3 Points to 5 named pictured objects when asked to do so 19 Points to left and right sides of body
4 Follows one-step instructions that include simple 20 Can state what is silly or wrong with pictures (e.g. Ano
prepositions (e.g., in, on, under, etc.) ang mali sa larawang ito?)
5 Follows 2-step instructions that include simple 2 Matches upper and lower case letters
prepositions
1
SELF HELP DOMAIN BoSY EoSY Total Raw Score
Total Raw Score
P O R P O R
1 Feeds self with finger foods (e.g. biscuits, bread) using
fingers. P- Present
2 Feeds self using fingers with spillage. O-Observed
3 Feeds self using spoon with spillage. R- Reported by parent/guardian
4 Feeds self using fingers without spillage.
5 Feeds self using spoon without spillage. BoSY EoSY
Eats without need for spoon feeding during any meal. EXPRESSIVE LANGUAGE P O R P O R
6