Child’s Name: ______________________________ Division of Cavite

SOCIO- EMOTIONAL BoSY EoSY

Sex:_________ Date of Birth:__________________ Municipality of General Mariano Alvarez
DOMAIN
P O R P O R Address: __________________________________ San Gabriel II Elementary School
S.Y. 2017-2018
1
Enjoys watching activities of people or nearby Child’s Handedness: (Check Appropriate Box)
animals.
Right Left Not yet established
Friendly w/ strangers but may initially show slight
2
shyness.
Father’s Name: ______________________________
Plays alone but likes to be near to familiar adults or
3
brother and sister. Occupation:_________________________________ Early Childhood Care and
4 Laughs or squeals aloud in play. Educational Attainment: _______________________ Development (ECCD)
5 Plays peek-a-boo (bulaga). Mother’s Name:______________________________
6 Rolls ball interactively with caregiver/ examiner.
Occupation:_________________________________
Educational Attainment: _______________________
7 Hugs or cuddles toys. Checklist
Demonstrates respect for elders using “po” and SUMMARY OF ASSESMENT
8
“opo”.
Shares toys with others familiar adults or brother and
9
sister.
BoSY EoSY
10 Imitates adults activities (e.g. cooking, washing) Date Assessed
Pupil’s Age
11 Identifies feelings of others. Domains RS SC RS SC

Appropriately uses cultural gestures of greetings Gross-Motor

12
without much prompting( e.g. mano/bless, kiss, etc.) Fine Motor
Self-Help Name: __________________________
13 Comforts playmates/siblings in distress.
Receptive Language Sex: __________________
Persists when faced with a problem or obstacle to his
14 Expressive Language
wants. Birthday: __________________
Cognitive
Helps with family chores(e.g. wiping tables, watering
15
plants) Socio-emotional LRN: -
Curious about environment but knows when to stop Sum of Scaled Scores
16
asking questions to adult.
Standard Scores
RS – Raw Score To the Parents:
17 Waits for turns. SC – Scaled Score The Philippine Early Childhood Care and Development Checklist
Asks permission to play with toys being used by (Form 2) contains knowledge, skills, and attitudes of children 3 – 5.11 years
18 old. This may be used as a guide in knowing your child and consequently give
others. INTERPRETATION appropriate care and teaching to guide their growth and development.
19 Defends possessions with determination.
BoSY:
Plays organized group games fairly(e.g. does not
20
cheat in order to win).
__________________
Can talk about difficult feelings (e.g. anger, sadness, PARENT’S SIGNATURE
21
worry) he experience. DAISY M. ABENOJAR
Teacher
22
Honors a simple bargain with caregiver (e.g., can EoSY: ___________________________
play outside only after cleaning/fixing his room)
ERNESTO B. ESGUERRA, Ed.D
Watches responsibly over younger siblings/family Principal IV
23
members.
Cooperates with adults and peers in group situations
24
to minimize quarrels and conflicts. PARENT’S SIGNATURE
GROSS MOTOR DOMAIN BoSY EoSY
Total Score Republic of the Philippines P O R P O R
Department of Education 1 Climbs on chair or elevated piece of furniture like a
Region IV-A CALABARZON bed without help
PUPIL’S SOCIO-DEMOGRAPHIC PROFILE
2 Walks backward. 8 Drinks from cup with spillage. 3 Uses 2-3 words verb-noun combinations (e.g. hingi
9 Drinks from cup unassisted. gatas)
3 Runs without tripping or falling.
Names objects in pictures
4
4 Walks down stairs, 2 feet on each step, with one 10 Gets drink for self unassisted. Speaks in grammatically correct 2-3 word sentences
5
hand held. 11 Pours from pitcher without spillage. 6 Asks “what” questions
5 Walks upstairs holding handrail, 2 feet on each step.
12 Prepares own food/snacks. 7 Asks “who”' and “why” questions
6 Walks upstairs with alternate feet without holding Gives account of recent experiences (with prompting)
13 Prepares meals for younger siblings/ family members 8
handrail. in order of occurrence using past tense
Walks downstairs with alternate feet without holding when no adult is around.
7 Total Score
handrail. 14 Participates when being dressed.
8 Moves body part as directed. 15 Pulls down gartered short pants.
9 Jumps up 16 Removes sando.
1 Throws ball overhead with direction. 17 Dresses without assistance except buttons and tying.
0 18 Dresses without assistance including buttons and tying.
1 Hops 1 to 3 steps on preferred foot. Informs the adult only after he has already urinated
1 19 (peed) or moved his bowels (pooped) in his
COGNITIVE DOMAIN BoSY EoSY
1 Jumps and turns. underpants. P O R P O R
Informs adult of need to urinate (pee) or move bowels 1 Looks at direction of fallen object
2
20 (poop) so he can be brought to a designated place 2 Looks for partially hidden object
1 Dances patterns/joins group movement activities.
(e.g. comfort room) 3 Imitates behavior just seen a few minutes earlier
3 Goes to the designated place to urinate (pee) or move
Total Score 21 bowels (poop) but sometimes still does this in his 4 Offers object but will not release it
underpants. 5 Looks for completely hidden object
Goes to the designated place to urinate (pee) or move 6 Exhibits simple pretend play (feed, put doll to sleep)
22 bowels (poop) and never does this in his underpants
anymore 7 Matches objects
23 Wipes/Cleans self after a bowel movement (poop) 8 Matches 2 – 3 colors
Participates when bathing (e.g. rubbing arms with 9 Matches pictures
BoSY EoSY 24
soap)
FINE MOTOR DOMAIN 10 Sorts objects based on 2 attributes (e.g., size and
P O R P O R 25 Washes and dries hands without any help.
Uses all five fingers to get food/toys placed on flat surface.
color)
1 26 Washes face without any help. 11 Sorts objects based on 2 attributes (e.g.,shape and
2 Picks up objects with thumb and index finger. 27 Bathes without any help. color)
Displays a definite hand preference. 12 Arranges objects according to size from smallest to
3 Total Score biggest
Puts small objects in/out of containers. 13 Names 4 – 6 colors
4
5
Holds crayon with all fingers of his hand making a fist (i.e. 14 Copies shapes
palmar grasp)
6 Unscrews lid of container or unwraps food. 15 Names 3 animals or vegetables when asked
7 Scribbles spontaneously. 16 States what common household items are used for
8 Scribbles vertical and horizontal lines. 17 Can assemble simple puzzles
9 Draws circle purposely. BoSY EoSY 18 Demonstrates an understanding of opposites by
10
Draws a human figure (head, eyes, trunk, arms, RECEPTIVE LANGUAGE P O R P O R completing a statement (e.g., Ang aso ay malaki, ang
hands/fingers) 1 Points to family member when asked to do so
Draws a house using geometric forms. daga ay _____”)
11 2 Points to 5 body parts on himself when asked to do so 19 Points to left and right sides of body
Total Score 3 Points to 5 named pictured objects when asked to do so
20 Can state what is silly or wrong with pictures (e.g. Ano
4 Follows one-step instructions that include simple
ang mali sa larawang ito?)
prepositions (e.g., in, on, under, etc.)
2 Matches upper and lower case letters
5 Follows 2-step instructions that include simple
prepositions 1
Total Score Total Score
SELF HELP DOMAIN BoSY EoSY
P O R P O R
1 Feeds self with finger foods (e.g. biscuits, bread) using
P- Present
fingers. O-Observed
2 Feeds self using fingers with spillage. R- Reported by parent/guardian
3 Feeds self using spoon with spillage.
4 Feeds self using fingers without spillage. BoSY EoSY
5 Feeds self using spoon without spillage. EXPRESSIVE LANGUAGE P O R P O R
6 Eats without need for spoon feeding during any meal. 1 Uses 5-20 recognizable words
7 Helps hold cup for drinking. 2 Uses pronouns (e.g. I, me, ako, akin)