REPUBLIC OF THE PHILIPPINES

PROVINCE OF BULACAN
PROVINCIAL SOCIAL WELFARE AND DEVELOPMENT OFFICE

SUMMARY OF SIX (6) TOOLS

(ECCD Checklist, Intake Sheet, Parent Information, Growth Chart, Observation, and Sample of Art Works)

Date: ___________________
(Date of Assessment)

Name of Child: ________________________________________________

Age: ______________

1. Siya ay ipinanganaksa __________________________________________ noong ________________.

(Lugar ng Kapanganakan) (Petsa ng kapanganakan)

2. Ang kanyang mga magulang ay sina __________________________ at __________________________.

(Pangalan ng ama) (Pangalan ng ina)

Si ______________________ ay ____________________.
(Pangalan ng bata) (Pang-ilan sa magkakapatid)

Sila ay ___________________________________________________________________.
(Estado ng pamumuhay/pamilya ;hal. Mababa, Gitna, Mataas)

3. Ang kanyang timbang ay __________, at ang kanyang taas ay ____________.

(kg) (cm)

Ang kalagayan ng kanyang kalusugan ay ______________________________.

(Normal, Below-normal, Severe, OW)

4. Siya ay ______________________________________________________________________________.
(Obserbasyon sa bata)

5. Base sa kanyang mga ginagawa, siya ay ____________________________________________________.

(Obserbasyon sa mga ginawang aktibidad ng bata)

6. Ayon sa kabuuang pagtatala sa ECCD checklist, siya ay _______________________________________.

(Kabuuang iskor / interpretasyon)

Prepared by: Noted by:

______________________________ _______________________
CDW MSWD Officer
 REPUBLIC OF THE PHILIPPINES
PROVINCE OF BULACAN
PROVINCIAL SOCIAL WELFARE AND DEVELOPMENT OFFICE

Name of CDC: __________________________________________

Name of CDW: __________________________________________
Location: _______________________________________________

RESULT OF ASSESSMENT BASED ON ECCD CHECKLIST

Name of Child: __________________________________________ Age: _________

Place of Assessment: __________________________________________

Gross Motor:
__________________________________________________________________________________________
__________________________________________________________________________________________
__________________________________________________________________________________________

Fine Motor:
__________________________________________________________________________________________
__________________________________________________________________________________________
__________________________________________________________________________________________

Self-Help
__________________________________________________________________________________________
__________________________________________________________________________________________
__________________________________________________________________________________________

Receptive Language:
__________________________________________________________________________________________
__________________________________________________________________________________________
__________________________________________________________________________________________

Expressive Language:
__________________________________________________________________________________________
__________________________________________________________________________________________
__________________________________________________________________________________________

Cognitive:
__________________________________________________________________________________________
__________________________________________________________________________________________
__________________________________________________________________________________________

Socio-Emotional:
__________________________________________________________________________________________
__________________________________________________________________________________________
__________________________________________________________________________________________

Prepared by: Noted by:

______________________________ _______________________
CDW MSWD Officer
 REPUBLIC OF THE PHILIPPINES
PROVINCE OF BULACAN
PROVINCIAL SOCIAL WELFARE AND DEVELOPMENT OFFICE

Name of CDC: __________________________________________

Name of CDW: __________________________________________
Location: _______________________________________________

INDIVIDUALIZED EDUCATION PLAN (IEP)

Name of Child: ______________________________________________ Age: _________

DOMAINS SCALED SCORE SCALED SCORE INTERPRETATION

Gross Domain
Fine Motor
Self-Help
Receptive Language
Expressive Language
Cognitive
Socio-Emotional
Sum of Scaled Score
Standard Score
Total Interpretation

Nutritional Status: _______________________

Talents, Skills, Interest: _______________________

Goal:
___________________________________________________________________
___________________________________________________________________
___________________________________________________________________
___________________________________________________________________
___________________________________________________________________

Objectives:
___________________________________________________________________
___________________________________________________________________
___________________________________________________________________
___________________________________________________________________
___________________________________________________________________
___________________________________________________________________
___________________________________________________________________
___________________________________________________________________
___________________________________________________________________

Prepared by: Noted by:

______________________________ ___________________________
CDW MSWD Officer
 REPUBLIC OF THE PHILIPPINES
PROVINCE OF BULACAN
PROVINCIAL SOCIAL WELFARE AND DEVELOPMENT OFFICE

OBSERVATION CARD

Name of Child: ________________________________________________ Age: _________

Setting: _________________________ Time: __________________ Date: ________________________

Actual Observation:
____________________________________________________________
____________________________________________________________
____________________________________________________________
____________________________________________________________
____________________________________________________________
____________________________________________________________
__________________________________________

Child Discussion ( if weakness/usual habits have been seen):

____________________________________________________________
____________________________________________________________
____________________________________________________________
____________________________________________________________
____________________________________________________________
____________________________________________________________

Prepared by: Noted by:

______________________________ _____________________
CDW MSWD Officer

Name of CDC: __________________________________________

 REPUBLIC OF THE PHILIPPINES
PROVINCE OF BULACAN
PROVINCIAL SOCIAL WELFARE AND DEVELOPMENT OFFICE

Name of CDW: __________________________________________

Location: _______________________________________________

PARENT’S CONFERENCE

Name of Child: ________________________________________________ Age: _________

Strength (Kalakasan):
____________________________________________________________
____________________________________________________________
____________________________________________________________
____________________________________________________________
____________________________________________________________

Weakness (Kahinaan):
____________________________________________________________
____________________________________________________________
____________________________________________________________
____________________________________________________________
____________________________________________________________
____________________________________________________________

Agreement (Pinagkasunduan para sa pag-unlad ng kakayahan ng bata):

____________________________________________________________
____________________________________________________________
____________________________________________________________
____________________________________________________________
____________________________________________________________
Prepared by: Noted by:
______________________________ ______________________
CDW MSWD Officer
 REPUBLIC OF THE PHILIPPINES
PROVINCE OF BULACAN
PROVINCIAL SOCIAL WELFARE AND DEVELOPMENT OFFICE

Name of CDC: __________________________________________

Name of CDW: __________________________________________
Location: _______________________________________________

FAMILY ASSESSMENT

Date: _________________

Name of Child: ____________________________________________ Age: _________________

History of Child’s Family (Include picture of house)

____________________________________________________________
____________________________________________________________
____________________________________________________________
____________________________________________________________
____________________________________________________________
____________________________________________________________
____________________________________________________________
____________________________________________________________
____________________________________________________________
____________________________________________________________
____________________________________________________________
____________________________________________________________
____________________________________________________________
____________________________________________________________
____________________________________________________________
____________________________________________________________
____________________________________________________________
____________________________________________________________
____________________________________________________________
________________________________________________________
Prepared by: Noted by:
______________________________ ______________________
CDW MSWD Officer

Name of CDC: __________________________________________

 REPUBLIC OF THE PHILIPPINES
PROVINCE OF BULACAN
PROVINCIAL SOCIAL WELFARE AND DEVELOPMENT OFFICE

Name of CDW: __________________________________________

Location: _______________________________________________

COMPUTATION OF AGE IN MONTHS

Name of CDC: _________________________________________

Name of CDW: _________________________________________
 REPUBLIC OF THE PHILIPPINES
PROVINCE OF BULACAN
PROVINCIAL SOCIAL WELFARE AND DEVELOPMENT OFFICE

Location: ______________________________________________

HEIGHT AND WEIGHT OF CHILDREN

FOR THE MONTH OF ______________

# Name of Children Date of Birthdate Age in Height Weight Nutritional Remarks

Weighing Months in cm. in kg. Status

Total Number of Children: _______

Normal Weight: _______ Severe Under Weight: ______
Under Weight: _______ Over Weight: ______

Prepared by: Noted by:

_________________________________ _______________________
CDW MSWD Officer

Name of CDC: _________________________________________

Name of CDW: _________________________________________
 REPUBLIC OF THE PHILIPPINES
PROVINCE OF BULACAN
PROVINCIAL SOCIAL WELFARE AND DEVELOPMENT OFFICE

Location: ______________________________________________

MASTERLIST OF CHILDREN
FOR THE MONTH OF ______________

# Name of Children Age Birthdate Gender Remarks

Total Number of Children: _______

Male: ______ Female: ______

2.7 to 3 yrs. Old : ______ 2.7 to 3 yrs. Old : ______

3.1 to 3.11: ______ 3.1 to 3.11: ______
4 yrs. Old: ______ 4 yrs. Old: ______

Prepared by: Noted by:

_____________________________
CDW
MSWD Officer
 REPUBLIC OF THE PHILIPPINES
PROVINCE OF BULACAN
PROVINCIAL SOCIAL WELFARE AND DEVELOPMENT OFFICE

Name of CDC: _________________________________________

Name of CDW: _________________________________________
Location: ______________________________________________

Distributions of Weekly Learning Plan

Week ___________

# Name of Parent Name of Children Time Signature Retrieval Time

 REPUBLIC OF THE PHILIPPINES
PROVINCE OF BULACAN
PROVINCIAL SOCIAL WELFARE AND DEVELOPMENT OFFICE

TIME FRAME
 REPUBLIC OF THE PHILIPPINES
PROVINCE OF BULACAN
PROVINCIAL SOCIAL WELFARE AND DEVELOPMENT OFFICE