Name: ______________________________ Nickname:

2.

GROSS
PRESE
COMMENTS
MOTOR
NT
Climbs on chair or other elevated
piece of furniture like a bed without
help.
Walks backwards

3.

Runs without tripping or falling.

4.

8.

Walks down stairs, 2 feet on each

step, with one held.
Walks upstairs holding handrail, 2
feet on each step.
Walks upstairs with alternate feet
without holding handrail.
Walks downstairs with alternate feet
without holding handrail.
Moves body parts as directed.

9.

Jumps up.

10
.
11
.
12
.
13

Throws ball overhead with direction.

1.

5.
6.
7.

1.
2.
3.
4.
5.
6.
7.
8.
9.
10
.
11
.
12
.
13
.

Hops 1-3 steps on preffered foot.

Jump and turn.
Dances patterns/joins group
movement activities.
TOTAL SCORE

________________
Date of Birth:_________________________ Age: ________
Sex: _______

1.
2.
3.
4.
5.
6.
7.
8.
9.
10
.
11

GROSS MOTOR DOMAIN

FINE MOTOR DOMAIN
FINE MOTOR
PRESE
NT
Uses 5 fingers to get food/toys
placed on flat surface.
Picks up objects with thumb and
index finger.
Display a definite hand preference.
Puts small objects in/out of
containers.
Holds crayon with all the fingers of
his hand making a fist(i.e, palmar
grasp)
Unscrews lid of container or
unwraps food.
Scribbles spontaneously.
Scribbles vertical and horizontal.
Draws circle purposely.
Draws a human figure( head, eyes,
trunk arms, hand /fingers).
Draws a house using geometric

14
.

COMME
NTS

15
.
16
.
17
.
18
.
19
.
20
.

21
.
22
.

forms.
TOTAL SCORE
SELP-HELP DOMAIN
SELP-HELP
PRESE
NT
Feeds self with finger food(e.g,
biscuits, bread) using fingers.
Feeds self using spoon with spillage
Feeds self using spoon without
spillage.
Feeds self using fingers with
spillage.
Fedds self using fingers without
spillage.
Eats without need for
spoonfeeding during any meal.
Helps hold cup for drinking.
Drinks from with spillage.
Drinks from cup unassisted.
Gets drink for self unassisted.

COMME
NTS

23
.
24
.
25
.
26
.
27
.

1.
2.
3.
4.

Pours from pitcher without

spillage.
Prepares own food/snack.

5.

Prepares meals for younger

siblings/family members when no
adults is around.
Participates when being
dressed(e.g., raises arms or lifts
leg).
Pulls down gartered short pants.

1.
2.
3.

Redmoves sando.
Dresses without assistance
including buttons and tying.
Dresses without assistance except
for buttons and tying.
Informs the adult only after he has
already urinated (peed) or moved
his bowels (poohed) in his
underpants.
Informs adult of need to urinate
(pee) or moved bowels (poohpooh) so he can be brought to
designated place (e.g. comfort
room).
Goes to the designated place to
urinate (pee) or move bowels
(pooh) and never does this is his
underpants anymore>
Goes to the designated place to
urinate (pee) or move bowels
(pooh) and never does does this is

4.
5.
6.
7.
8.

1.
2.
3.
4.
5.
6.
7.

his underpants anymore.

Wipes/clean self after a bowel
movement..
Participates when bathing (e.g.
Rubbing with soap).
Washes and dries hands without
any help.
Washes face without any help.
Bathes withou any help.
TOTAL SCORE
RECEPTIVE LANGUAGE
RECEPTIVE LANGUAGE
PRESE
COMMENT
NT
S
Points to family members when
asked to do so.
Points to 5 body parts on himself
when asked to do so.
Points 5 named picturd objects
when asked to do so.
Follws one-step instructions that
include simple prepositions (e.g.
in, on, under, etc.)
Follows 2-step instructions that
include simple preposition.
TOTAL SCORE
EXPRESSIVE LANGUAGE DOMAIN
EXPRESSIVE LANGUAGE
PRESE
COMMEN
NT
TS
Uses 5-20 recognizable words.
Uses pronouns (e.g. I, me, ako, akin)
Uses 2-3 words verb-noun combinations
(e.g. hingi gatas).
Names objects in pictures.
Speaks in grammatically correct 2-3 word
sentences.
Asks what questions.
Aks who questions.
Gives account of recent experiences
(with prompting) in order of occurence
using past tense.
TOTAL SCORE
COGNITIVE DOMAIN
COGNITIVE
PRESE
COMMEN
NT
TS
Looks at direction of fallen object.
Looks dor partially hidden object.
Immitates behavior just seen a few
minutes earlier.
Offers object but will not release it.
Looks for completely hidden object.
Exhibits simple pretend play (feed, put
doll to slep).
Matches objects.

8.
9.
10
.
11
.
12
.
13
.
14
.
15
.
16
.
17
.
18
.
19
.
20
.
21
.

1.
2.
3.
4.
5.
6.
7.
8.
9.
1
0.
1
1.
1
2.
1

Matches 2-3 colors.

Matches pictures.
Sorts based on shapes.

3.
1
4.
1
5.
1
6.

Sorts objects based on 2 attributes (e.g.

size and color).
Arranges objects according to size from
smallest to biggest>
Names 4-6 colors.

1
7.
1
8.
1
9.
2
0.
2
1.

Asks permission to play with toy

being used by another.
Defends
possessions
with
determination.
Plays organized group games fairly
(e.g. does not cheat in order to win).
Can talk about difficult feelings (e.g.
PARENTS/GUARDIAN
NAME
anger,
sadness,
worry)
he
experiences.
SIGNATURE
2
Honors a simple bargain with
JUNE
2.
caregiver (e.g. can play outside only
after cleaning/fixing his room).
OCTOBER
2 MARCH
Watches responsibly over younger
3.
siblings/family members.
2
Cooperates with adults and peers in
4.
group situations to minimize quarrels
and conflicts.
TOTAL SCORE

Copies shapes.
Names 3 animals or vegetables when
asked.
States what common household item
are used for.
Can assemble simple puzzles.
Demonstrates an understanding of
opposites by completing a statement
(e.g. Ang aso ay malaki. Ang daga ay
maliit.)
Points to left and right side of the body.
Can state what is silly on wrong with
pictures (e.g. Ano ang mali sa larawang
ito?)
Matches upper and lower case letters.
TOTAL SCORE
SOCIAL EMOTIONAL DOMAIN
SOCIAL-EMOTIONAL
PRESE
NT
Enjoys watching activities of nearby
people or animals.
Friendly with strangers but initially
may show slight anxiety or shyness.
Plays alone but likes to be near
familliar adults or brothers and
sisters.
Laughs or squels aloud in play.
Plays peek-a-boo (bulaga).
Rolls
ball
interactively
with
caregiver/examiner.
Hugs or cuddles toys.
Demonstrates respect for elders
using terms like po and opo.
Shares toys with others.
Immitates
adult
activities
(e.g.
cooking, washing)
Identifies feelings in others.
Appropriately uses cultural gestures
of greeting without much prompting
(e.g. mano, bless, kiss, etc.)
Comforts
playmates/siblings
in

distress.
Persists when faced with problem or
obstacle to his wants.
Helps with family chores( e.g. wiping
tables, watering plants, etc.)
Curious about environment but
knows when to stop asking questions
of adults.
Waits for turn.

AND

Republic of the Philippines

Department of Education
Region V BICOL
Buhi South DIstrict
CAGMASLOG ELEMENTARY SCHOOL

COOME
NTS

Philippine Early Childhood

Development Checklist
JUNE
Sum of
Scaled
Scores
Standard
Score
Interpretat
ion of
Standard
Score

OCTOBER

MARCH

Form 2
(3.0-5.11 years old)

Childs Name:
Birthdate:

Age:

S.Y: 20162017

LRN:

MARIA IRENE B. MORANTE

VICTORIA CARULLA
SCHOOL HEAD
TEACHER

Sex: Male

MA.