Republic of the Philippines

Department of Education
Region V Bicol
Division of Catanduanes
Virac South District

Philippine Early Childhood

Development Checklist (FORM 2)
AGES 3 YEARS 1 MONTH TO 5 YEARS 11 MONTHS
SCHOOL YEAR 2015 2016
CHILDS NAME:
HANDEDNESS:
BOTH

SEX:

MALE

FEMALE

LRN: 0
LEFT

RIGHT

UNESTABLISHED
BIRTH DATE:

AGE:

GRADE LEVEL:

KINDERGARTEN
AS OF:

CHILDS

ADDRESS:
CHILDS

FATHERS

EDUCATIONAL

CIVIL

FATHER:
ATTAINMENT:

OCCUPATION:

AGE:

STATUS:

CUSTODIAL
PARENT:

CHILDS

MOTHERS

EDUCATIONAL

CIVIL

MOTHER:

YES /
NO

AGE:

ATTAINMENT:

STATUS:

OCCUPATION:

CUSTODIAL

YES

PARENT:
AGE OF MOTHER WHEN

BIRTH ORDER (CHILD):

SHE HAD THE CHILD:

ND

GUARDIAN (IF

RD

NO

ST

OTHERS: ___
RELATIONSHIP:

APPLICABLE):

__________________

TO THE PARENTS:
The Philippine Early Childhood Development Checklist (Form 2) contains
knowledge, skills and attitudes of children 3 5.11 years old. This may be
used as a guide in knowing your child and consequently give appropriate care
and teaching to guide their growth and development.

CONTENT:
Every page contains different domains of development with their
corresponding total scores:
- Gross Motor Domain has - Fine Motor Domain has
- Self-help Domain
13 items
11 items
has 27 items
- Receptive Language
- Expressive Language
- Cognitive Domain
Domain has 5 items
Domain has 8 items
has 21 items
- Social-Emotional Domain
has 24 items
Each item observed are recorded three times within a year:
(1) at the start of the year, (2) at the middle of the year, and (3) at the end of
the year.
COLUMNS
P Present or the child can do the
O Observed or the child was
R Report given by the
-

__________________________
ADVISER
GROSS MOTOR DOMAIN
A 3.1 4.0

M
M
M

SCORE
Present or child is able to do
Skill is not present or child
0 no opportunity to observe the
-

__________________________
SCHOOL PRINCIPAL I

PREMIDPOSTASSESSMEN ASSESSMEN ASSESSMEN

T
T
T

COMME
COMM
P O R COMME
NTS P O R NTS P O R ENTS

.
Climbs on chair or other
1 elevated piece of furniture like
a bed without help

2 Walks backwards
B
4.1 5.0
.

3 Runs without tripping or falling

down stairs, 2 feet on

4 Walks
each step, with one hand held

upstairs holding handrail,

5 Walks
2 feet on each step
upstairs with alternate
6 Walks
feet without holding handrail

downstairs with alternate

7 Walks
feet without holding handrail
8 Moves body part as directed
9 Jumps up

1 Throws ball overhead with

0 direction
C 5.1 5.11
1

Hops 1 to 3 steps on preferred

1 foot
1
2

Jumps and turns

Dances patterns/joins group

3 movement activities
TOTAL SCORE
SCALED SCORE
FINE MOTOR DOMAIN

PREMIDPOSTASSESSMEN ASSESSMEN ASSESSMEN

T
T
T

A
3.1 4.0
.

COMME
COMM
P O R COMME
NTS P O R NTS P O R ENTS

Feeds self with finger foods

1 (e.g., biscuits, bread, etc.)
using fingers

2 Feeds self with fingers to eat

rice / viands with spillage
3 Displays a definite hand
preference

4 Puts small objects in/out of

containers

Holds crayon with all fingers of

5 his hand making a fist (I.e.,
palmar grasp)
B
4.1 5.0
.
lid of container or
6 Unscrews
unwraps food
7 Scribbles spontaneously

FINE MOTOR DOMAIN

vertical and horizontal
8 Scribbles
lines
C 5.1 5.11
9 Draws circle purposely
1 Draws a human figure (head,
eyes, trunk, arms,
0 hands/fingers)
1

Draws a house using

1 geometric forms
TOTAL SCORE

PREMIDPOSTASSESSMEN ASSESSMEN ASSESSMEN

T
T
T

COMME
COMM
P O R COMME
NTS P O R NTS P O R ENTS

SCALED SCORE

SELF-HELP DOMAIN
A
3.1 4.0
.
Feeds self with finger food
1 (e.g., biscuits, bread, etc.)
using fingers

2 Feeds self using fingers with

spillage
3 Feeds self using spoon with
spillage
4 Feeds self using fingers
without spillage

5 Feeds self using spoon without

spillage
B
4.1 5.0
.
without need for spoon
6 Eats
feeding during any meal
7 Helps hold cup for drinking

8 Drinks from cup with spillage

C 5.1 5.11
9 Drinks from cup unassisted
1
0

Gets drink for self unassisted

Pours from pitcher without

1 spillage
1
2

Prepares own food/snack

PREMIDPOSTASSESSMEN ASSESSMEN ASSESSMEN

T
T
T

COMME
COMM
P O R COMME
NTS P O R NTS P O R ENTS

1 Prepares meals for younger

siblings/family members when
3 no adult is around
1 Participates when being
dressed (e.g., raises arms or
4 lifts leg)
1

Pulls down gartered short

5 pants
1
6

Removes sando

Dresses without assistance

7 except for buttons and tying

SELF-HELP DOMAIN
1

Dresses without assistance

8 including buttons and tying
1 Informs the adult only after he
has already urinated (peed) or
9 moved his bowels (poohed) in
his underpants
Informs adult of need to
2 urinate (pee) or move bowels
(pooh-pooh) so he can be
0 brought to a designated place
(e.g., comfort room)

2 Goes to the designated place

to urinate (pee) or move
1 bowels (pooh) and never does
this is his underpants anymore
2 Goes to the designated place
to urinate (pee) or move
2 bowels (pooh) and never does
this is his underpants anymore

PREMIDPOSTASSESSMEN ASSESSMEN ASSESSMEN

T
T
T

COMME
COMM
P O R COMME
NTS P O R NTS P O R ENTS

Wipes/Cleans self after a

3 bowel movement (pooh)
2

Participates when bathing (e.g.,

4 rubbing arms with soap)
2

Washes and dries hands

5 without any help
2
6
2
7

Washes face without any help

Bathes without any help
TOTAL SCORE
SCALED SCORE

PREMIDPOSTASSESSMEN ASSESSMEN ASSESSMEN

T
T
T
RECEPTIVE LANGUAGE DOMAIN
COMME
COMM
P O R COMME
NTS P O R NTS P O R ENTS
A
3.1 5.11
.
1 Points to 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
5 Follows 2-step instructions that
include simple prepositions
TOTAL SCORE
SCALED SCORE

EXPRESSIVE LANGUAGE
A
3.1 5.0
.

PREMIDPOSTASSESSMEN ASSESSMEN ASSESSMEN

T
T
T

COMME
COMM
P O R COMME
NTS P O R NTS P O R ENTS

1 Uses 5-20 recognizable words

2
3

Uses pronouns (e.g., I, me,

ako, akin)

Uses 2-3 words verb-noun

combinations (e.g., hingi gatas)

4 Names objects in pictures

B
5.1 5.11
.
5

Speaks in grammatically correct

2-3 word sentences

6 Asks whatquestions
7

Asks who and why

questions

Gives account of recent

8

experiences (with prompting) in

order of occurrence using past
tense
TOTAL SCORE
SCALED SCORE
COGNITIVE DOMAIN

PREMIDPOSTASSESSMEN ASSESSMEN ASSESSMEN

T
T
T

A
3.1 4.0
.

COMME
COMM
P O R COMME
NTS P O R NTS P O R ENTS

1 Looks at direction of fallen

object
2 Looks for partially hidden
object

3 Imitates behavior just seen a

few minutes earlier
4 Offers object but will not
release it

5 Looks for completely hidden

object
6 Exhibits simple pretend play
(feeds, puts doll to sleep)
7 Matches objects
B
4.1 5.0
.
8 Matches 2-3 colors
9 Matches pictures
1
0

Sorts based on shapes

Sorts objects based on 2

1 attributes (e.g., size and color)

COGNITIVE DOMAIN
1

Arranges objects according to

2 size from smallest to biggest
1 Names 4-6 colors

PREMIDPOSTASSESSMEN ASSESSMEN ASSESSMEN

T
T
T

COMME
COMM
P O R COMME
NTS P O R NTS P O R ENTS

3
1
4

Copies shapes

Names 3 animals or
5 vegetables when asked
1

States what common

6 household items are used for
C 5.1 5.11
1
7

Can assemble simple puzzles

1 Demonstrates an understanding
of opposites by completing a
8 statement (e.g., Ang aso ay
malaki, ang daga _____)
1

Points to left and right sides of

9 body
2 Can state what is silly or
wrong with pictures (e.g. Ano
0 ang mali sa larawang ito?
2

Matches upper and lower case

1 letters
TOTAL SCORE
SCALED SCORE

SOCIAL-EMOTIONAL DOMAIN
A
3.1 5.0
.

PREMIDPOSTASSESSMEN ASSESSMEN ASSESSMEN

T
T
T

COMME
COMM
P O R COMME
NTS P O R NTS P O R ENTS

1 Enjoys watching activities of

nearby people or animals

Friendly with strangers but

2 initially may show slight anxiety
or shyness
Plays alone but likes to be
3 near familiar adults or brothers
and sisters
4 Laughs or squeals aloud in
play
5 Plays peek-a-boo (bulaga)

6 Rolls ball interactively with

caregiver/examiner
7 Hugs or cuddles toys
B
5.1 5.11
.
Demonstrates respect for
8 elders using terms like po
and opo
9 Shares toys with others

1 Imitates adult activities (e.g.,

0 cooking, washing)
SOCIAL-EMOTIONAL DOMAIN
1 Identifies feelings in others
1

Appropriately uses cultural

1 gestures of greetings without
2 much prompting (e.g., mano,
kiss, etc.)

1 Comforts playmates/siblings in
3 distress
when faced with a
1 Persists
problem
4 wants or obstacle to his

PREMIDPOSTASSESSMEN ASSESSMEN ASSESSMEN

T
T
T

COMME
COMM
P O R COMME
NTS P O R NTS P O R ENTS

with family chores (e.g.,

1 Helps
wiping
5 etc.) tables, watering plants,

about environment but

1 Curious
knows
when
to stop asking
6 questions of adults
1 Waits for turn
7

1 Asks permission to play with a

8 toy being used by another
1 Defends possessions with
9 determination

organized group games

2 Plays
fairly
(e.g.,
does not cheat in
0 order to win)
Can talk about difficult /
2 negative feelings (e.g., anger,
1 sadness, worry) he
experiences.

Honors a simple bargain with

2 caregiver (e.g., can play
2 outside only after
cleaning/finishing his room)
responsibly over
2 Watches
younger
siblings/family
3 members

with adults and

2 Cooperates
peers
in
group
situations to
4 minimize quarrels
and conflicts
TOTAL SCORE
SCALED SCORE
ASSESSMEN
T
SUMMARY

PR
E

TOTA
L

SCAL
ED

MID TOTA
L

SCAL

GROSS
MOTOR
DOMAIN

FINE
MOTOR
DOMAIN

RECEPTIV EXPRESSI
SOCIOVE
SELF-HELP
E
COGNITIVE EMOTIONA
DOMAIN
LANGUAGE LANGUAGE
DOMAIN
L DOMAIN
DOMAIN
DOMAIN

ED

PO
ST

TOTA
L

SCAL
ED

ASSESSMENT

PRE: ___ /
___ / _____
MID: ___ /
___ / _____
POST: ___ /
___ / _____

COMMENTS

EXAMINERS /
TEACHERS
NAME AND
SIGNATURE

PARENTS /
CAREGIVERS
NAME AND
SIGNATURE