Republic of the Philippines

Department of Education
Region III – Central Luzon
Schools Division of Tarlac Province

JOSE V. YAP NATIONAL HIGH SCHOOL

 

 
Assessment Tool FORM 1
 
  CHECKLIST ON AN INTERVIEW IN IDENTIFYING A CHILD WITH AUTISM
 
Name of the Child: _____________________________________ Age: ________
Address: _____________________________________________
 
Directions:
 
1. Interview the informant by asking him to evaluate objectively the child suspected with autism based
on his observation of and interactions with the child.
2. Based on the interview, rate the child along each item by checking under the
column that best describes him/her.
 
 Legend:
HC = Highly Characteristic of the Child
CC = Characteristic of the Child
SC = Slightly Characteristic of the Child
NC = Not Characteristic of the Child
 
 

CHARACTERISTICS HC CC SC NC
1. Exhibits normally consistent eye contact.        
2. Plays with other children.        
3. Relates positively with other people.        
4. Exhibits appropriate emotional responses.        
5. Behaves properly in varied places.        
6. Imitates sounds/words taught to him/her and appropriate for his/her        
skill level.
7. Imitates gestures/movements taught to him/her and appropriate for        
his/her skill level.
8. Exhibits non-repetitive hand/body movements or “rituals”: walking to        
and fro, whirling, jumping, etc.
9. Demonstrates impulse control/non-hyperactive behaviors.        
10. Plays with varied objects.        
11. Plays with toys appropriately.        
12. Attends to sounds and voice especially when talked to.        
13. Behaves normally when hearing loud or faint sounds.        
14. Attends to objects/materials/items/other visuals/seen/presented to        
him/her.
15. Focuses on given tasks with adequate attention span.        
16. Adapts to changes in food/clothes/arrangements of things/fixtures.        
17. Adapts to changes in routines/routes.        
18. Explores new objects in age-appropriate ways of tasting, smelling and        
touching.
19. Manifests normal fear or nervousness.        
20. Discriminates and avoids dangers including seeking attention when        
hurt or sick and localizing internal/external pains.
21. Communicates meaningfully and normally considering his/her age        
and given situations.
22. Performs age-appropriate/grade-expected language-conceptual skills        
such as reasoning, inferential thinking, deductive and inductive thinking
 and interpreting.
23. Possesses age-appropriate maturity level.        
24. Performs normally and consistently well in academics.        
 
 

 
Scoring and Interpretation:
 
1. HC gets zero ( 0 ), CC1 point, SC 2 points and NC 3 points.
 
2. The perfect score is 72 points.
 
3. After checking and completing the scale, get the sum of the scores.
 
4. Determine the equivalent interpretation of the child’s total score using the
following:
 
 
Score Interpretation
 
15 – 33 Without Autism
34 – 39 Has Mild Autism
40 – 45 Has Moderate Autism
46 – 72 Has Severe Autism
 
Note:
 
After detecting the presence of autism, a SPED diagnostician confirms or negates the result through the
process of identification utilizing varied tools and strategies.
 
 
 
 
 
 
____________________________ _____________________
         PRE-ASSESSED BY                 DATE
 
 
____________________________ _____________________
         CONFORMED BY                 DATE
 

Republic of the Philippines

Department of Education
 Region III – Central Luzon
Schools Division of Tarlac Province

JOSE V. YAP NATIONAL HIGH SCHOOL

 

Assessment Tool FORM 2.1

 
 
TEACHER OBSERVATION CHECKLIST FOR THE GIFTED
 
 

Name of the Child: _________________________________

Age: _______ Sex: ______
 
  Definition:
 
A gifted child is one who is capable of superior performance and this includes demonstrated
achievement or potential ability in one or more of these areas: general intellectual ability, specific
academic aptitude, creative or productive thinking ability, leadership ability, ability in the visual or
performing arts, and psychomotor ability.
 
Directions: Put a check (√) on the observed characteristics.
 
_______1. Is easily bored with routine tasks
_______2. Has a keen sense of humor
_______3. Enjoys the company of adults more than his peers
_______4. Has an unusual retentive memory
_______5. Adjust easily to new situations
_______6. Likes to be a leader and directs activities
_______7. Strives to do his best in whatever he does
_______8. Can concentrate for long periods of time
_______9. Has high standard for work and high expectations of others
_______10. Carries his responsibilities well
_______11. Asks a lot of provocative and intelligent questions
_______12. Often gives unusual and unique clever response
_______13. Requires little supervision from teacher/adult
_______14. Likes to take risks and is not afraid to be different
_______15. Shows superiority in the visual and performing arts like drawing, singing, playing musical
instruments, painting and the like
_______16. Knows about many things other children of his age are unaware
_______17. Has superior reasoning ability
_______18. Has a large well developed vocabulary compared to others of the same
age
_______19. Has a high degree of imagination and originally in ideas
_______20. Learns fast and understands easily
 
 
Score: _______
 
Interpretation:
A pupil who shows these characteristics can be a fast learner or gifted child.
 

 
____________________________ _____________________
         PRE-ASSESSED BY                 DATE
 
 
____________________________ _____________________
         CONFORMED BY                 DATE
Republic of the Philippines
Department of Education
 Region III – Central Luzon
Schools Division of Tarlac Province

JOSE V. YAP NATIONAL HIGH SCHOOL

 

Assessment Tool FORM 3.1

 

CHECKLIST FOR THE IDENTIFICATION OF AN INTELLECTUAL DISABILITY CHILD

 
 

Name of the Child: _________________________________

Age: _______ Sex: ______
 
 Definition:

A child with a mental retardation is one who has significantly sub-average general intellectual
functioning existing currently with deficits in adaptive behavior and manifested during the
developmental period.
 
Direction: Put a checkmark (√) on the space corresponding to the characteristics manifested by the pupil
being observed.
 
_______1. Has a poor gross motor coordination as in jumping, skipping, hopping
_______2. Finds difficulty in cutting, buttoning, zipping and tying shoe lace
_______3. Can hardly trace/copy simple letters and numbers
_______4. Is unable to do personal needs independently
_______5. Has difficulty in discriminating similar or different objects
_______6. Is unable to understand time concept of “today”, “yesterday”, “last  
week”
_______7. Can hardly color within lines
_______8. Has poor memory
_______9. Can hardly finish work that has been started
_______10. Repeats activities over and over again
_______11. Has difficulty in reading labels and signs
_______12. Has limited vocabulary as compared with peers
_______13. Is easily frustrated
_______14. Has short attention span
 
 
Interpretation:
A pupil who manifests the characteristics maybe intellectually disabled so other tests should be given to
him/her.
 
 
 

____________________________ _____________________
         PRE-ASSESSED BY                 DATE
 
 
____________________________ _____________________
         CONFORMED BY                 DATE

Republic of the Philippines

Department of Education
 Region III – Central Luzon
Schools Division of Tarlac Province

JOSE V. YAP NATIONAL HIGH SCHOOL

 

Assessment Tool FORM 5.1

CHECKLIST FOR THE IDENTIFICATION OF A VISUALLY IMPAIRED CHILD

Name of the Child: ______________________________   Age: _______  

Sex: ________
 
 Definition:
Visually impaired children have been referred to as either blind or with low vision.
A blind child is one whose visual acuity is 3/60 or 10/200 or less in better eye with correcting
glasses or with insufficient vision for daily activities.
A child with low vision is one who has a low degree of vision 6/18 or 20/60 and can read only
enlarged print or a limited amount of standard reading materials.
 
Direction:Put a checkmark (√) on the space corresponding to the behavior or condition
manifested by the child suspected of having visual impairment.
 
I. Physical Condition
_______1. Has red rims on eyelids
_______2. Has blurred vision
_______3. Is cross-eyed
_______4. Has one/both eyes that are permanently closed
_______5. Has protruding eyeball/s
 
II. Observable Behavior
_______6. Rubs the eyes frequently
_______7. Blinks continuously
_______8. Holds the book too close or too far away when reading
_______9. Shuts or covers one eye when reading or looking at other objects
_______10. Tilts the head to one side when reading or looking at other objects
_______11. Stumbles or trips over objects when playing or working
_______12. Screws up the force when looking at distant objects
_______13. Unable to see light
_______14. Unable to distinguish and lacks normal curiosity
_______15. Unable to see printed page
 
Score = _______________
 
Scoring:
A pupil who manifests these behaviors may have a visual impairment. For further testing, the
teacher may use an E chart or Snellen Chart with the help of the clinic teacher or SPED Teacher
for the visually impaired. The child may also be referred to an eye specialist or ophthalmologist
for diagnosis.
 
____________________________ _____________________
         PRE-ASSESSED BY                 DATE
 
 
____________________________ _____________________
         CONFORMED BY                 DATE

Republic of the Philippines

Department of Education
 Region III – Central Luzon
Schools Division of Tarlac Province

JOSE V. YAP NATIONAL HIGH SCHOOL

 

Assessment Tool FORM 6

 
CHECKLIST FOR THE IDENTIFICATION OF A HEARING IMPAIRED CHILD
 
 
Name of the Child: ___________________
Age: _____ Sex: ____    
 
Definition:
A hearing impaired child is one who is deaf or hard of hearing. A person is deaf if his hearing is
non-functional for ordinary purpose of life. A hard or hearing individual has a sense of hearing
which although defective, is functionally with or without a hearing aid.
 
Direction:Put a checkmark (√) on the space corresponding to the characteristics manifested by
the pupil being observed.
 
________1. Makes use of more natural gesture signs and movements to express
                        himself
________2. Fails to respond to question
________3. Usually has no speech
________4. If he has speech, he:
4.1 tends to have articulatory problems like omission, addition of sounds onwords, phrases and
sentences
4.2 has unintelligible speech
________5. Watches face especially the mouth and the lips of the speaker when talk to
________6. Moves closer to speaker when talked to
________7. Has closed ear canal(s)
________8. Has no outer ear(s)
________9. Has discharging ear(s)
________10. Cups hands behind the ear to catch sound
________11. Cocks ear/tilts head at an angle
________12. Shows strained expression when listening
________13. Is less responsive to noise, voice or music
________14. Often asks for repetition of questions/statement
________15. Has blank facial expression when talked to
 
 
Interpretation:
A pupil who manifests these characteristics may be deaf or hard-of-hearing. He/she should be
referred to an ear specialist or audiologist if available for further testing.
 
 

____________________________ _____________________
         PRE-ASSESSED BY                 DATE
 
 
____________________________ _____________________
         CONFORMED BY                 DATE