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Department of Education

Region: ______________________________________
Division: _____________________________________
City/Municipality: _______________________________

District: __________________________________________
Barangay: ________________________________________
School: ___________________________________________

Sex

Raw
Score

Scaled
Score

Raw
Score

Submitted by:
_____________________________________
Name of Teacher

Scaled
Score

Self-help
Domain
Raw
Score

Scaled
Score

Receptive
Domain
Raw
Score

Scaled
Score

Expressive
Domain
Raw
Score

Scaled
Score

Cognitive
Domain
Raw
Score

Scaled
Score

Social
Emotional
Domain
Raw
Score

Scaled
Score

NOTED:
_____________________________________
School Head

Not Ready

Age

Fine Motor

Ready

Name of Pupils

Gross Motor

Remarks
Day-Care

No. of Items which the child failed to exhibit/perform per domain

Sum of Scaled
Score
Standard
Score

SUMMARY REPORT ON EARLY CHILDHOOD DEVELOPMENT CHECKLIST ECCD FOR KINDERGARTEN