\Rev. 02.10.

09 Profile ID (to be filled up by the encoder)

Republic of The Philippines Child Information Sheet
Department of Social Welfare and Development
Early Childhood Care and Development
l. Identifying Information NOTE: Fields with (*) asterisk are required fields.
1.Facility

Location
Name of Facility * Barangay* City/ Municipality* Province* Region*

2.a. Name 2b. Nickname Last Name*

Last Name First Name* Middle Name* Ext. (Jr. Sr)

3. Sex Male Female 4a. Birth Order* 4b. No. of Siblings* 5a. Date of Birth*
YYYY - MM - DD

6. Birth Place 5b. Birth Registered?* Yes No

Barangay* City / Municipality Province* Region

7. Home
Address
No. & Street Address Barangay* City / Municipality* - Province* Region*

8. Religion 9. Ethnicity

II. Family Information (use additional sheets as necessary.)

11a. Full Name* b. Birthday c. Relationship d. Sex e. Civil Status f. Highest Education* g. Occupation h. Monthly Income
1.
2.
3.
4.
5.
6.
7.
8.
III. Nutrition and Services

12. The child underwent the following: (check all applicable and fill details.) 13. The child has the following disabilities/ Impairments
A. Disability/Impairment (e.g. hearing, speech ,visual) b.Cause (e.g.newbornillness
Breastfeeding – breastfed for
1.
months 2.
Supplemental Feeding- supplemented for 3.
4.
Days 5
6.
Food for School (Ree Distribution) – weekly allotment of 14.The child has the following past ECCD experiences:
a. Service Type* b. Service* c. From (Start Date) d. To (enddate)
kg
(e.g. Center, community) (e,g Child Minding, (YYYY.MM.DD) (YYYYMMDD)
Assessment or assistance for a Disability from: care mother)

Government Hospital / Clinic / Medical Personal

Private Hospital / Clinic / Medical Personal

Others:
___________________________________
15a. Participants Fee 16. Schedule*

Paid Amount of: Morning Season Accomplished By:

Date Accomplishment*
P
Afternoon Season

15b. Parents* Counterpart* 17. Attendance If drop out, Reason: YYYY MM DD

Cash
In Kind Continuing illness Encoder ID
None Dropped Out Transfer Of Residence ______________________________________
Others (specify): Name and Signature of ECCD Service Provider*
_______________

Page1
Rev. 01.18.09 Profile ID (copy from 1* page)
Republic of The Philippines
Department of Social Welfare and Development
Child Information Sheet
Early Childhood Care and Development
17a. Health Service* b. Date YYYY-MM-DD* a. Health Services* b. Date YYYY-MM-DD
1.Newborn Screening 25
2. BCG vaccination (at birth) 26
3. DVT Vaccination (6.20 & 14 weeks old) 27
4. OPV Vaccination ( 6.20 & 14 weeks old) 28
5. Hepatitis B Vaccination (6.20 & 14 weeks old) 29
6. Measles Vaccination (9 m0nths) 30
7. Vitamin A ( Starting from 6 months) 31
8. Deworming 32
9. Dental Check up 33
10. Physical Check up 34
11. Micronutrient Supplement 35
12 36
13 37
14 38
15 39
16 40
17 41
18 42
19 43
20 44
21 45
22 46
23 47
24 48
VI. Nutritional Status (use additional sheets as necessary)VII. Developmental Status ( using the ECCD checklist)
18a. Date YYYY-MM- b. Age* c.Weight kg* d. NutriotionalStatus* 19.Evaluation* 1st Evaluation 2nd Evaluation 3nd Evaluation
DD
1. Evaluation Date*
(YYYY-MM-DD)
2. Domains Raw Score Scaled Score Raw Score Scaled Raw Score Scaled Score
a. Fine Motor Dev’t Score
3. b. Gross Motor
c. Self-Help
4. d. Receptive Language
5. e. Expressive Language
6. f. Cognitive
7. g. Socio- Emotional
8.
9.
10.
11. OVERALL Interpretation
12.
13. Nutritional Status Development Status Interpretation Raw Score 1-150
14 Weight-for-Age 1. Highly Advanced Scale Score 1-19
Referenc

15 Underweight 2. Slightly Advanced

16 1. <-2D Normal 3. Average Development
e

17 2. – 29D to -29D Overweight4. Development to be mentioned after 5 months

3. >-29D 5. Development to be mentioned after 3 months
18
19 Reviewed By:* Date Accomplished
20
21
22 YYYY - MM - DD
23 ______________________________________ Encoder ID
24 Name and Signature of ECCD Service Provider
Nutritional Status (e.g overweight, underweight, normal, malnourished)

V. Health Services: Have the Health Service Provider sign beside each entry (use additional sheets as necessary )

Page 2
PARENT INTERVIEW FORM/INTAKE
No. of the Family Members _______________
1) Gaano katagal ang oras at panahon na ginugugol mo para saiyong anak araw-araw?
________________________________________________________________________________________________
2) Anu-anong patakaran sabahay ang dapat sinusunod ng iyong mga anak
________________________________________________________________________________________________
3) Anu-anong mga pamamaraan ang pagdidisiplina ng iyong anak?
________________________________________________________________________________________________
________________________________________________________________________________________________
4) Anong mga balakid o sagabal ang iyong naranasan sa pagdidisiplina ng iyong anak?
________________________________________________________________________________________________
5) Kung mayroon man, paano mo ito binibigyan solusyon?
________________________________________________________________________________________________
6) Ilang oras ba ginugugol ng iyong anak sa panonood ng TV? ______________________________________________
Sino ang sumusubaybay sa kanya sa panonood nito? ___________________________________________________
7) Mayroon bang kinakatakutan ang iyong anak? _________________________________ ______________________
Kung mayroon man, ano ang mga iyon
______________________________________________________________________________________________
______________________________________________________________________________________________
8) Nagkaroon na ba ng hindi inaasahang pangyayari sa buhay ng iyong anak? Halimbawa, aksidente,
Malubahang sakit, etc.
________________________________________________________________________________________________
________________________________________________________________________________________________
9) Anong allergies o gamut ang puedeng ibigay sa anak mo kung nilalagnat?
________________________________________________________________________________________________
10) Sa palagay, mo, mayroon bang kakaibang problema o pangangailangan ang iyong anak na nangangailangan ng
espesyal na atensiyon?
________________________________________________________________________________________________
Kung mayroon man, ano ang mga iyon? _______________________________________________________________
________________________________________________________________________________________________
11) Anu-ano ang mga rason/dahilan bakit gusto mong ipasok at pag-aralin ang iyong anak sapaaralang ito?
________________________________________________________________________________________________
12) Anu-ano ang iyong mga inaasahan na matutuhan at malalaman ng iyong anak sapagpasok sapaaralang ito?
_________________________________________________________________________________________________
13) Interesado ka bang dumalo sa study group meeting para lalong matuto tungkol sa Montessori Approach
Education at ECCD _____________________________________________ ____________________________________
Ilang oras bang maari mong ilaan?
____________________________________________________________________________________________
14) Anong uring pakikipag-ugnay ang iyong inaasahan mula sa paaralan at saiyong tahanan?
_________________________________________________________________________________________________
_________________________________________________________________________________________________
15) Anu-anong pang mgabagay ang iyong iminumungkahi para sa kabutihan ng iyong anak at paaralan?
_________________________________________________________________________________________________
EMERGENCY CONTACT:
Names TELEPHONE/ADDRESS
_________________________________________ _____________________________________________
_________________________________________ _____________________________________________
Page 3
 KASUNDUAN
Ako, kami si ___________________________________ at ___________________________________,
Mga magulang, tagapag-alagang batang si ____________________________________________________ _____
Ay nangangakong susunod salahat ng mga alituntunin para sa mga pamilyang pinagkalooban ng mga biyaya at
karapatang ipasok sa DAYCARE Service Program sa pangangasiwa ng Municipal Social Welfare and
Development Office,

Ang mga sumusunod na alintuntuning nauukol sa mga magulang ng batang sumali sa programa:

1. Nararapat na malinisang katawan, ngipin at pananamit ng mga bata sa araw-araw pagpasok sa paaralan.

2. Kailangang dumalo sa mga pulong ukol sa mga magulang at guro minsan isangbuwan at kung mayroong
di pangkaraniwang pangyayari o panayam.

3. Kailangang tumulong sapaglilinis sasilid-aralan, banyo at palikurang ginagamit ng mga bata.

4. Kailangang tumulong sapagaalaga ng halaman sa paligid ng paaralan ayon sa tungkuling itatakda ng guro.

5. Kailangang tumulong sapaghanda ng pagkain ng mga batang nag-aaral at maglinis ng silid-aralan

Sa bawat paggamit (case to case basis)

6. Kailangan tumulong sa paggawa at pangangalaga ng mga kasangkapan, kagamitan ng paaralan.

7. Kailangan sumunod sa mga patakaran naitinakda ng Day Care Center.

8. Bilang competent partners, kailangangi sanggunis a Day Care ang anumang mungkahi, suliranin
O problema patungkols a Day Care Service program upang mapag-usapan.

Sang-ayon:

_______________________________ _____________________________
Pirma ng Ina Pirma ng Ama

___________________________
Pirma ng Guro

__________________________________
MSWDO/ECCD Focal Person

Date : ____________________________

Page 4

BIRTH CERTIFICATE
 Page 5

BCYW-DCS Form No. 5

 INITIAL AND ANNUAL HEALTH RECORD
(For Use of the Physician)

I. Maternal History: Please Check illness/es during pregnancy

_________ Goiter __________ German Maesles
_________ Diabetes __________ Hepatitis
_________ Tuberculosis __________ Sexually Transmitted Disease
_________ Heart Disease __________ Others (specify please)
II. Brief History:
A. Type of Delivery
______________ Normal Spontaneous Delivery
______________ Caesarean Section
______________ Forced
B. Place of Delivery
______________ Hospital
______________ Home
______________ Others (Please specify)
C. State Complications if any ________________________________________________________
__________________________________________________________________________________
D. Allergies, if any: ________________________________________________________________
__________________________________________________________________________________
III. Immunization: Dates Given
DPT _________________ _________________
POLIO _________________ _________________
BCG _________________ _________________
MEASLES _________________ _________________
IV. Deworming Dates of Last Deworming
__________ Yes _________________ _________________
__________ No _________________ _________________
V. Disabilities/Impairments: Please check if any:
__________ Congenital Deformities ___________ Speech Defect
__________ Deafness ___________ Emotional Disturbances
__________ Others (Please specify)
VI. Previous Illness Date
________________________ _________________________
________________________ _________________________
VII. Current Health Status
_________________________________________________________________________________________
_________________________________________________________________________________________
_____________________________________________________________________________
VIII. Pertinent Physical Examination:
HEENT _________________________________
Chest/Lungs _____________________________
Abdomen ________________________________
GUT ____________________________________
NUERO _________________________________
IX. Remarks
_________________________________________________________________________________________
_________________________________________________________________________________________
_____________________________________________________________________________

____________________________
Signature of Physician
______________________________
Date_
Page 6
Growth Monitoring Chart

Page 7
 SCHOOL HEALTH EXAMINATION CARD
DETENTION STATUS AND TREATMENT NEEDS TREATMENT RECORD
Date Toot Nature of Dentist
STATUS h No Operation
RIGHT LEFT
TEMPORARY TEETH

STATUS

TREATMENT NEEDS
LEFT

PERMANENT TEETHDATE OF VISITS

1st 2nd 3rd 4th
Index D.M.F.T Year Year Year Year
No. T/decayed
No. T/Missing
No. T/filled
Total D.M.F.T
Total Sound

SYMBOLS FOR MOUTH EXAMINATION Artificial Restoration Symbols for Accomplishment

X – Carious tooth indicated for F2- Permanently filled JC-Jacket Crow n OP-prophylaxis
CF-Cement Extraction with recurrence AB- Abutment Xt-ExtractedZnc
F – Zinc Oxide F- Carious tooth indicated for
Heavy Shade-Permanent P- Pontic permanent tooth filling
Filling Filling I- inlay xt-Extracted
Corrected-Correction RF-Root Fragment
Outline of filling-Tooth with RPD-Removable temporary tooth of all defects O-missing tooth temporary
FB- Fixed Bridge Agf- Agmalgam TF-Treatment of Filling
CD-Complete Sy F- Synthetic R- Referred
(/) Sound Teeth Denture porcelain Filling to private dentist
GIC-Glass Ionmer cement.

Page 8
 It is recommended that the Checklist be administered to the child o nce a year

Computation of Child’s Age

After verifying the dates, compute the child’s age by subtracting the date he was born from the
date the test is administered. Each month is composed of 30 days. Do not round off the months
of years. Write the examiner’s name each time test is administered.

Year Month Day Examiner’s Name

Date Tested
1st Child’s Date of Birth
assessment Child Age
Date Tested
2nd Child’s Date of Birth
assessment Child Age
Date Tested
3rd Child’s Date of Birth
assessment Child Age

Page 9
GROSS MOTOR DOMAIN ECCD CHECK LIST
Gross Motor Present Comments
1stEval. 2ndEval. 3rdEval.
1. Climbs on chair or other elevated piece of
furniture like a bed without help.
2. Walks backwards
3 .Run without tripping or falling
4. Walks downstairs,. 2 feet of each step, with
one hand held
5. Walks upstairs holding onto handrail, 2 feet o
each step
6. Walk upstairs with alternate feet without
holding onto a handrail
7. Walks downstairs with alternate feet without
holding onto a handrail
8. Moves body part as directed
9. Jumps up
10. Throws ball overhead with direction
11. Hops 3 steps on preferred foot
12. Jumps and turns
13. Dances patterns/joins group movement
activities
TOTAL SCORE

FINE MOTOR DOMAIN

Fine Motor Present Comments
1stEval. 2ndEval. 3rdEval.
1. Uses all 5 fingers to get food/tops placed on a
flat surface
2.Piks up objects with thumb & index finger
3. Display a definite hand preference
4. Puts small objects in/out of containers
5. Holds crayon with all the fingers on his hand
as thought making a first (i.e palmar grasp)
6. Unscrews the lid of a container/unwraps
foods
7. Scribbles spontaneously
8. Scribbles vertical and horizontal lines
9. Draw circle purposefully
10. Draw a human figure (head, eyes, trunk,
arms, hands/fingers)
11. Draw a house using geometric forms
TOTAL SCORE
Page 10

SELF-HELP DOMAIN
Self-Help Present Comments
 1stEval. 2ndEval. 3rdEval.
1 Feeds self with finger food (e.g. biscuits, bread)
using fingers
2 Feeds using fingers to eat rice/viands with spillage
3 Feeds self using spoon with spillage
4 Feeds self using fingers without spillage
5 Feeds self using spoon without spillage
6 Eats without need for spoon feeding during any
meal.
7 Helps hold cup of drink
8 Drinks from cup with spillage
9 Drinks from cup unassisted
10 Gets drink for self unassisted
11 Pours from pitcher without spillage
12 Prepares own food/snack
13 Prepares meats foe younger siblings/family
members when no adult is around.
Dressing Domain
14 Participates when being dressed (e.g. raise arms
or lifts leg)
15 Pulls down gartered shorts pants
16 Removes sando
17 Dresses without assistance except buttoning and
tying
18 Dresses without assistance, including buttoning
and tying
Toilet Training sub-domain
19 Informs the adult only after he has already
urinated (peed) or moved his bowels (poohed) in
his underpants
20 Informs the adult need to urine (pee) or move
bowels (pooh-pooh) so he can be brought to a
designated place (e.g. CR)
21 Goes to the designated place to urine (pee) or
moves bowels (pooh) but sometimes still does
this in underpants
22 Goes to the designated place to urine (pee) or
move bowels (pooh) and never does this in his
underpants anymore
23 Wipes/cleans self after a bowel movement (pooh)
24 Participates when bathing (e.g. rubbing arms with
soap )
25 Washes and dries hands without any help
26 Washes face without any help
27 Bathes without any help
TOTAL SCORE
Page 11

RECEPTIVE LANGUANGE DOMAIN

Receptive Language Present Comments
1stEval. 2ndEval. 3rdEval.
1 Points to a family member when asked to do so
2 Points to 5 body parts on himself when asked to do
so
3 Points to 5 named pictured objects when asked to do
 so
4 Follows one-step instructions that include simple
prepositions (e.g. in, on, under. Etc.)
5 Follows 2-step instructions that include simple
prepositions
TOTAL SCORE

EXPRESSIVE LANGUAGE DOMAIN

Expressive Language Present Comments
1stEval. 2ndEval. 3rdEval.
1 Uses 5 to 20 recognizable words
2 Uses pronouns (e.g. I, me, ako, akin)
3 Uses 2-to-3 word verb-noun combinations (e.g. hingi,
gatas)
4 Names objects in pictures
5 Speaks in grammatically correct 2-to-3 word
sentences
6 Asks “what” questions
7 Asks “who” and “why” questions
8 Gives account of recent experiences (with prompting)
in order to occurrence using past tense
TOTAL SCORE

Page 12

COGNITIVE DOMAIN
Cognitive Language Present Comments
1stEval. 2ndEval. 3rdEval.
1 Looks to the direction of a fallen object
2 Looks for a partially hidden object
3 Imitates behaviour just seen a few minutes earlier
4 Offers an object but may not release it
5 Looks for a completely hidden object
6 Exhibits simple “pretend ” play (i.e. puts doll to
sleep)
7 Matches objects
8 Matches 2 to 3 colors
9 Matches pictures
10 Sorts based on shapes
11 Sorts objects based on attributes (e.g. size and color)
12 Arranges objects according to size from smallest to
biggest
13 Names 4 to 6 colors
14 Copies shapes
15 Names 3 animals or vegetables when asked
16 States what common household items are used for
17 Can assemble simple puzzles
18 Demonstrate an understanding of opposites by
completing a statement (e.g. “Ang aso ay malaki,
and daga ay ___________.”)
19 Points to left and right sides of body
20 Can state what is silly or wrong with pictures (e.g.
Anoangmalisalarawangito?)
21 Matches upper case letters; and matches lower case
letters
TOTAL SCORE

Page 13

SOCIAL-EMOTIONAL DOMAIN
Social-Emotional LanguagePresent Comments
1stEval. 2ndEval. 3rdEval.
1 Enjoys watching activities of nearby people or
animals
2 Friendly with strangers but initially may show slight
anxiety or shyness
3 Plays alone but likes to be near familiar adults or
brothers and sisters
4 Laughs or squeals aloud in play
5 Plays peak-a-boo (bulaga)
6 Rolls ball interactively with caregiver/examiner
7 Hugs or cuddles toys
8 Demonstrates respect for elders using terms like
“po” and “opo”
9 Share toys with others
10 Imitates adult activities (e.g. cooking, washing)
11 Identifies feelings in others
12 Appropriately uses cultural gestures of greeting
without much prompting ?(e.g. mano, bless, kiss,
etc.)
13 Comforts playmates /siblings in distress
14 Persists when faced with a problem or obstacles to
his wants
15 Helps with family chore (e.g. wiping tables,
watering plants, etc.)
16 Curious about environment but knows when to
stop asking questions of adults
17 Waits for his turns
18 Asks permissions to play with toy being used by
another
19 Defends possessions with determination
20 Plays organized group games fairly (e.g., does not
cheat to win)
21 Can talk about complex feelings (e.g., anger,
sadness, worry) he experiences
22 Honors a simple bargain with caregiver (e.g., plays
outside only after cleaning/fixing his/her room)
23 Watches responsively over younger siblings/family
members
24 Cooperates with adults and peers in group
situations to minimize quarrels and conflicts
TOTAL SCORE

Page 14

Transfer the raw for each domain to the table below. Using the Scaled Score Equipment of Raw
Scores Table, convert the raw scores to Scaled Scores appropriate to the age of the child. To
arrive at the sum of the scaled scores, add the scaled scores across alldomains. To derive the
Standards Score Equipment of Sums of Scaled Scores Table. Write the child’s age on each
evaluation.
A G E
Domain 1 Eval. Date: ________
st

Child’s Age: _________

2 Eval. Date: ________
nd

Child’s Age: _________

3rdEval. Date:
________
Child’s Age:
_________
Raw Score Scaled Score Raw Score Scaled Score Raw Score Scaled
Score

Gross Motor

Fine Motor

Self-Help

Receptive
Language

Expressive
Language

Cognitive
 Social-Emotional
Sum of Scaled
Scores
Standard Score

Interpretation

Interpretation of Scaled Score: Interpretation of Standard Score:

Scale Interpretation
Score
Overall development must be
67 and below
monitored after 3 months
Overall development must be
70 – 9
monitored after 6 months
Average overall development
80 – 119
Slightly advance overall development
120 129
Highly advance overall development
130 and
above
Page 15

Scale Interpretation
Score
Development in the domain must be
1-3
monitored after 3 months

4-6
SCALED SCORES
Development in the domain must be
monitored after 6 months
Average overall development in the domain
Mark
7 - 13 an x on the dot corresponding to the Scaled Score for each domain and connect the
x’s.– 16 Suggests
Write slightly age
the child’s advanced development
on each in
evaluation.
14
the domain
Suggest highly advanced development in
17 - 19
the domain
 Child’s Age______________ Child’s Age_____________ Child’s Age_____________

DOMAIN DOMAIN DOMAIN

EXPRESSIVE LANGUAGE

EXPRESSIVE LANGUAGE

EXPRESSIVE LANGUAGE
SOCIAL-EMOTIONAL

SOCIAL-EMOTIONAL

SOCIAL-EMOTIONAL
MOTOR

MOTOR

MOTOR
FINE MOTOR

FINE MOTOR

FINE MOTOR
COGNITIVE

COGNITIVE

COGNITIVE
SCALED

SCALED

SCALED
RECEPTIVE

RECEPTIVE

RECEPTIVE
LANGUAGE

LANGUAGE

LANGUAGE
SELF-HELP

SELF-HELP

SELF-HELP
SCORE

SCORE

SCORE
GROSS

GROSS

GROSS
19 . . . . . . . 19 . . . . . . . 19 . . . . . . .
Suggests advanced

18 . . . . . . . 18 . . . . . . . 18 . . . . . . .
Development

17 . . . . . . . 17 . . . . . . . 17 . . . . . . .
16 . . . . . . . 16 . . . . . . . 16 . . . . . . .
15 15 15
. . . . . . . . . . . . . . . . . . . . .
14 14 14
. . . . . . . . . . . . . . . . . . . . .
13 13 13
. . . . . . . . . . . . . . . . . . . . .
12 12 12
11
. . . . . . . 11
. . . . . . . 11
. . . . . . .
10
. . . . . . . 10
. . . . . . . 10
. . . . . . .
9
. . . . . . . 9
. . . . . . . 9
. . . . . . .
8 . . . . . . . 8 . . . . . . . 8 . . . . . . .
7 . . . . . . . 7 . . . . . . . 7 . . . . . . .
6 . . . . . . . 6 . . . . . . . 6 . . . . . . .
5 . . . . . . . 5 . . . . . . . 5 . . . . . . .
4 . . . . . . . 4 . . . . . . . 4 . . . . . . .
3 . . . . . . . 3 . . . . . . . 3 . . . . . . .
2 . . . . . . . 2 . . . . . . . 2 . . . . . . .
1 1 1
. . . . . . . . . . . . . . . . . . . . .
. . . . . . . . . . . . . . . . . . . . .

Page 16

STANDARD SCORES
Mark an x on the corresponding Standard Score for each test administration and
connect the x’s. Write the date for each test administration.
 A G E S
3 years & 1 month 4 years 5 years
________
________ ________ ________ ________
160 ________ ________ ________ ________
________ ________ ________ ________
150 ________ ________ ________ ________
________ ________ ________ ________
140 ________ ________ ________ ________
________ ________ ________ ________
________ ________ ________ ________
130
________ ________ ________ ________
________ ________ ________ ________
120 ________ ________ ________ ________
________ ________ ________ ________
110 ________
________ ________ ________ ________
100 ________ ________ ________ ________
________ ________ ________ ________
________ ________ ________ ________
90
________ ________ ________ ________
________ ________ ________ ________
80
________ ________ ________ ________
________ ________ ________ ________
70 ________ ________ ________ ________
________ ________ ________ ________
60 ________ ________ ________ ________
________ ________ ________ ________
________ ________ ________ ________
50
________ ________ ________ ________
________ ________ ________ ________
40 ________ ________ ________ ________

Date Tested

Page 17

Scaled Score Equivalent of Raw Scores Table

Child’s Record 2
 Ages 3.1-4.0 years Ages 4.1-5.0 years
Scaled Gross Fine Self-Help Receptive Expressive Cognitive Social Scaled Gross Fine Self-Help Receptive Expressive Cognitive Social
Score Motor Motor raw score Language Language raw Emotional Score Motor Motor raw score Language Language raw Emotional
raw score raw score raw score raw score raw score raw score raw score raw score raw score raw score
1 0-3 0-3 0-9 - 0-2 - 0-9 1 0-5 0-3 0-15 0-1 - 0 0-13
2 4 0-3 10 - - - 10-11 2 6 4 16 - 0-5 1 14
3 5 - 11 0-1 3 0 12 3 - - 17 2 - 2-3 15
4 - 4 12 - 4 1 13 4 7 5 18 - - 4 16
5 6 5 13-14 2 - 2-3 14 5 8 6 19 - 6 5 17
6 7 - 15 - 5 4 15 6 - - 20 3 - 6-7 -
7 8 6 16 3 - 5 16 7 9 7 - - - 8 18
8 9 - 17 - 6 6 17-18 8 10 - 21 - 7 9-10 19
9 - 7 18-19 - - 7 19 9 - 8 22 4 - 11 20
10 10 8 20 4 7 8-9 20 10 11 9 23 - - 12 21
11 11 - 21 - - 10 21 11 12 - 24 5 8 13-14 22
12 12 9 22 5 8 11 22 12 - 10 25 - - 15 23
13 - - 23-24 - - 12 23 13 13 - 26 - - 16-17 24
14 13 10 25 - - 13-14 24 14 - 11 27 - - 18 -
15 - 11 26 - - 15 - 15 - - - - - 19-20 -
16 - - 27 - - 16 - 16 - - - - - 21 -
17 - - - - - 17 - 17 - - - - - - --
18 - - - - - 18 - 18 - - - - - - -
19 - - - - - 19-21 - 19 - - - - - - -

Ages 5.1-5.11 years

Scaled Gross Fine Self-Help Receptive Expressive Cognitive Social

Score Motor Motor raw Language Language raw Emotiona

raw score raw score score raw score raw score l raw score
score
1 0-10 0-5 - 0-2 - 0-9 0-15
2 - - 0-19 - - 10 16
3 - 6 20 - - 11 17
4 11 - 21 3 - 12 -
5 - 7 - - 0-7 13 18
6 - - 22 - - 14 19
7 12 8 23 - - 15 20
8 - 9 - 4 - 16 -
9 - - 24 - - 17 21
10 - 10 25 - - 18 22
11 13 - - 5 8 19 23
12 - 11 26 - - 20 -
13 - - 27 - - 21 24
14 - - - - - - -
15 - - - - - - -
16 - - - - - - -
17 - - - - - - -
18 - - - - - - -
19 - - - - - - -

Page 18

Growth Chart
Record Informationalong the month-of-weighing line using the symbols below:
W - Weight
 F - Fever
B - Breastfeeding
C - cold/cough
C/F - complementary foods introduced
D - diarrhea
OI - other illness
A - Vitamin A given
H - hospitalized
I - signs of injuries such as
Abrasions/hematoma
5-6 years

4 – 5 years

3 – 4 years

61 62 63 64 65 66 67 68 69 70 71 72

49 50 51 52 53 54 55 56 57 58 59 60

*+SD – Standard

37 38 39 40 41 42 43 44 45 46 47 48

Age in Months

Month of Weighing

How to Interpret the

Growth Chart
As a child gets older, he/she should gain
weight

The child’s weight should be between the A Child who is ... A child who is...
“reference” curves. The plotted growth curve Not gaining weight has plotted growth Losing weight has a plotted growth curve that goes
should go in upward direction. curve that flattensoff or looks like a flat in a downward/declining direction between the
line between the “reference” curve. “reference” curves.

Page 19
Scaled Score Equivalent of Sum of Scaled Scores Table
Child’s Record 2

Sum of Scaled Standard Sum of Scaled Standard Scores

Scores Scores Scores
29 37 64 88
30 38 65 89
31 40 66 91
32 41 67 92
33 43 68 94
34 44 69 95
35 45 70 97
36 47 71 98
37 48 72 100
38 50 73 101
39 51 74 103
40 53 75 104
41 54 76 105
42 56 77 107
43 57 78 108
44 59 79 110
45 60 80 111
46 62 81 113
47 63 82 114
48 65 83 116
49 66 84 117
50 67 85 119
51 69 86 120
52 70 87 122
53 72 88 123
54 73 89 124
55 75 90 126
56 76 91 127
57 78 92 129
58 79 93 130
59 81 94 132
60 82 95 133
61 84 96 135
62 85 97 131
63 86 98 138

Page 20
 Core Development milestones of Filipino Children
MOTOR SELF-HELP LANGUAGE COGNITIVE SOCIO-EMOTIONAL

months

Throws ball overhead Baths Unassisted Recounts recent Matches upper and Uses cultural gesture or
with direction experiences in order lower case letter greeting without
of occurrence using prompts (e.g. mano,
past tense bless, kiss)
months
4 years

Draws a human figure or Uses toilet with Ask “WHAT”,”WHO” Arranges objects Play organized group
house occasional accidents and “WHY” questions according to size from games fairly
smallest to biggest

months
3 years
Runs without tripping Pulls down gartered Speak grammatically Matches objects and Imitates adult activities
shorts correct 2-3 words pictures (e.g., cooking, washing)

months
2 years
Holds crayons with Drinks from cup with Names objects in Exhibits simple pretend Rolls ball interactively
palmar grasp; Scribbles spillage pictures play (e.g., feed, put doll with caregiver
Spontaneously to sleep)

months
1 years& 6 months
Walks alone, rarely falls Feed self using spoon Combines single words Searches for complete Friendly with strangers
with spillage and gesture to make concealed object but initially, shows
wants known (e.g., anxiety or shyness
“out”)

months
1years
Stands with minimum Feeds self with fingers Uses meaningful Looks at direction of Cries when caregiver
support (biscuit, bread) sounds to refer to fallen object leaves
specific objects or
persons (e.g., “mama”,
“dada”)

months

Sit alone steadily Begin to take solid Turns head when Explores objects by Enjoys friendly handling
foods called by name, make biting or holding
eye contact

months

Holds head steadily Sucks and swallows Turns head toward Gazes slowly at mocing Smiles and lifts arms to
liquid sound objects great careguver

Ensure the best possible start in your child’s life. Monitoring your child’s develop
Page 21
 MONTHLY WEIGHT RECORD

AGE IN NUTRITIONAL STATUS

MONTH MOS. WEIGHT HEIGHT NORMAL UW SUW OW
June
July
August
Septembe
r
October
November
December
January
February
March
April
May

Page 22
 OBSERVATION NOTES

Name of the Child: _________________________________________________________

Age: ________________________

DATE DEVELOPMENTAL MILESTONES OBSERVATION

GROSS MOTOR FINE RECEPTIVE EXPRESSIVE SOCIO- COGNITIVE SELF-HELP

MOTOR LANGUAGE LANGUAGE EMOTIONAL

Page
23
 OBSERVATION NOTES

Name of the Child: _________________________________________________________

Age: ________________________

DATE DEVELOPMENTAL MILESTONES OBSERVATION

GROSS MOTOR FINE RECEPTIVE EXPRESSIVE SOCIO- COGNITIVE SELF-HELP

MOTOR LANGUAGE LANGUAGE EMOTIONAL

Page 24
 INDIVIDUAL PARENT CONFERENCES

NAME OF THE CHILD: _________________________________________________________

NAME OF PARENT/GUARDIAN INTERVIEWED: _____________________________________
RELATION TO THE CHILD : ____________________________________________________

DATE CHILD’S OBSERVATION FEEDBACK FROM PARENT AGREEMENT PARENT SIGNATURE

Page 25
 INDIVIDUAL PARENT ‘S CONFERENCES

NAME OF THE CHILD: _________________________________________________________

NAME Of PARENT /GUARDIAN INTERVIEWED: _____________________________________
RELATION TO THE CHILD : ____________________________________________________

DATE CHILD’S OBSERVATION FEEDBACK FROM PARENT AGREEMENT PARENT SIGNATURE

 Page 26

HOME VISITATION

DATE OBSERVATION/RECORDS PARENT’S INFORMATION ACTIVITIES UNDER

OF CHILD’S BEHAVIOR TAKEN/REMARKS
Page 27
 Dental Referral Form
OFC Referral Slip
Republic of the Philippines
Province of Catanduanes
Municipality of ______________
BARANGAY ____________

CHILD DEVELOPMENT CENTER________________

REFERRAL SLIP
DATE : _____________

NAME OF PUBLIC HEALTH DENTIST: _______________________________________________________

NAME OF HOSPITAL : __________________________________________________________
ADDRESS : __________________________________________________________
REFERRED PATIENT/CHILD :
NAME OF CHILD : ____________________________________AGE: _______ SEX : ______
ADDRESS : ___________________________________________________________
PARENT/GUARDIAN : ___________________________________________________________
OBSERVED DENTAL CONDITION : __________________________________________________________
__________________________________________________________

__________________________
NAME OF CDW
- - - - - - - - - - - - - - -- - - - - - - - - - - - - - - - - - - - - - - - - - - - ------- - - - - - - - - - - - - - - - - - - - - - - - - - - - -
Dental Referral Form
OFC Referral Slip
Republic of the Philippines
Province of Catanduanes
Municipality of __________________
BARANGAY ____________

CHILD DEVELOPMENT CENTER________________

DATE : _____________

TO : MR/MRS. : ___________________________
CHILD DEVELOPMENT CENTER : ___________________________

This is to inform you that ______________________________ , _________ years old, was

admitted at this clinic and upon oral examination was found to have the following findings :
1. ______________________________________________________________________________
2. ______________________________________________________________________________
3. ______________________________________________________________________________

TREATMENT DONE :
1. ______________________________________________________________________________
2. ______________________________________________________________________________
3. ______________________________________________________________________________

REMARKS : _________________________________________________________________________

______ ___________________
Public Health Dentist

Page 28
 ACCIDENT OR INCIDENT REPORT

INSTRUCTION :

Accomplish this form for any significant occurrence such as accident

or unusual problem or situation that may affect the physical,
emotional , and psychological condition of the child.

NAME OF CHILD : _______________________________________

DATE OF INCIDENT : _______________________________________
TIME OF INCIDENT : ________________________________________

EXPLANATION :

___________________________________________________________
___________________________________________________________
___________________________________________________________

ACTION TAKEN :

___________________________________________________________
___________________________________________________________
___________________________________________________________
___________________________________________________________

COMMENTS :

____________________________________________________________
____________________________________________________________

REPORTED BY :

_______________________ ________________________
( Name & Signature ) (Signature of CDW)

Page 29
DATE/MONTH CHILD NARRATIVE PROGRESS REPORT

JUNE

JULY

AUGUST

SEPTEMBER

OCTOBER

NOVEMBER

DECEMBER

JANUARY

FEBRUARY

MARCH

APRIL

MAY

Page 30
 CHILDREN’S MONITORING
DOMAIN RATING DOMAIN RATING
GROSS MOTOR 1st 2nd 3rd 4th 1st 2nd 3rd 4th
1. Runs without tripping Numeracy
2. Jumps in place with both feet 1. Points out which has more or less
3. Hops 1 to 3 steps on preferred foot 2. Counts up to 10 objects
4. Skips with alternate feet 3. Sequence numeral 1 - 10
5. Moves body parts as directed 4. Identify the missing number in sequence
6. Throws ball overhead with direction 5. Adds and subtracts combinations to 10
FINE MOTOR Reading Readiness
1. Holds crayon/pencil and scribbles spontaneously 1. Identifies the missing part of picture/object
2. Scribbles vertical and horizontal lines 2. Recites or sings the alphabet
3. Draws a human figure 3. Names upper and lower case letters
4. Draws a house 4. Matches letter without sound of letter
5. Colors within a line 5. Read 3-4 letter words
RECEPTIVE/EXPRESSIVE LANGUAGE 6. Sequence events and picture
1. Answers question about oneself 7. Identifies pictures that are the same
2. Uses simple greetings and courteous expressions 8. Identifies letters that are different
in appropriate situations 9. Identifies words that are the same
3. Follow one-step direction with simple prepositions 10. Associates word with picture
(e.g., in, on, under) Construction and Visual-Motor Integration
4. Follows two-step directions in identifying objects 1. Replicates a pattern by drawing
in term in position 2. Copies letter/numeral from model
5. Names 4-6 colors 3. Identifies the missing object in given pattern
COGNITIVE 4. Identifies the picture that give the
Sensory Discrimination and Seration/Classification appropriate ending of events/situation
1. Discriminates texture 5. Assembles simple puzzles
2. Arrange objects according to size from smallest TOTAL MASTERED SKILLS/DOMAIN
to biggest
3. Sorts objects based on two attributes READY (Y) Yes (N) No
4. Identifies same and different shapes
5. Draws geometric forms NOTE: Passing score is 34 which is 75 of the highest possible score (45).
Concept Formation A child who got the score of 34 and above is “READY” while the child
1. Groups and states functions of common house- with the score of 33 and below is considered as “NOT READY” to
hold items perform Grade work. (Checklist for Character Traits is not include in the
2. Shows/points to left and right side of body computation)
3. Completes statements showing simple analogy INSTRUCTION: When the child exhibits the skill, put a check in the
4. Identifies absurdities in pictures (e.g., corresponding skill. Put a Hypen (-) if the child cannot perform the task.
Anoangmalisalarawangito?) REFERRENCE: School Readiness Assessment (SReA) Tool.
5. Conserves number

Page 31