+

Name of the Child: ________________________________________________

Age: ___________________________________________________________
Address: ________________________________________________________
Day Care Center: _________________________________________________
S/Y: ___________________________________________________________
CHILD RECORD 1
CHILD RECORD 2
 I N TAK E
I. PERSONAL DATA
Name of Child _____________________________________ Age _________ Sex _______
Date/Place of Birth ___________________________________ Religion ____________________
Address __________________________________________________________________________
No. Street Zone Barangay City
1st Quarter 2nd Quarter 3rd Quarter
Height _______ Weight/Nutritional Status
Physical Disability, if any (specify): ___________________________________________________
Child’s Handedness (check appropriate box) [ ]Right [ ]Left [ ]Both [ ]Not yet established

II. FAMILY COMPOSITION

Family composition (include parents and all members of the family who live as one household.
(i.e. share dwelling, same source of income and the same kitchen.)
Name by Birth A S Civil Relation Educational Time Occupation Income Health Attitude
Order (Include G E Satus to Child Attainment Present Condi- Toward
child) E X at Home tion Child

III. DEVELOPMENT INFORMATION

1. Birth Certification: available _________________________ not available _________________
2. Marriage Contract: Date of marriage____________________ Registry No. ________________
3. Child Development Checklist _____________________________________________________
Check if child’s achievement on admission for day care service corresponds to 50% and above, of
indicators for his age, using the child development checklist:
_______ a. motor development _______ e. social values in relation to God
_______ b. personal-social development _______ f. social values in relation to self
_______ c. cognitive adoptive dev’t _______ g. social values in relation to family
_______ d. language competency _______ h. social values in reference to non-relative
_______ i. social values in reference country/community
IV. HOME CONDITIONS
1. Home conditions that are observed as likely detrimental to the child (e.g. mother working part of
the day but leaves no adequate adult supervision to child.)
_____________________________________________________________________________
2. Conditions in the neighborhood that are detrimental to the child (e.g. presence of gambling
places, near streets, etc.)
_____________________________________________________________________________

CHILD RECORD 3
 PARENT INTERVIEW FORM/INTAKE
No. of Family Members ________________________
1) Gaano katagal ang oras at panahon na ginugugol mo para sa iyong anak araw-araw?
_________________________________________________________________________
2) Anu-anong patakaran sa bahay ang dapat sinusunod ng iyong mga anak?
_________________________________________________________________________
3) Anu-anong mga pamamaraan ang pagdidisiplina mo sa iyong anak?
_________________________________________________________________________
4) Anong mga balakid o sagabal ang iyong nararanasan sa pagdidisiplina ng iyong anak?
_________________________________________________________________________
5) Kung mayroon man, paano mo ito binibigyan ng solusyon?
_________________________________________________________________________
6) Ilang oras ba ang ginugugol ng iyong anak sa panonood ng TV? _____________________
_________________________________________________________________________
7) Mayroon bang kinakatakutana ng iyong anak? ____________________Kung mayrooon
mana ano ang mga iyon______________________________________________________
8) Nagkaroon na ba ng hindi inaasahang pangyayari sa buhay ng iyong anak? Halimbawa,
aksidente malubhang sakit, etc. ________________________________________________
__________________________________________________________________________
9) Anong allergies o gamut ang pwedeng ibigay sa anak mo kung nilalagnat?
_________________________________________________________________________
10) Sa palagay mo, mayroon bang kakaibang problema o pangangailangan ang iyong anak na
nangangailangan ng espesyal na atensiyon?___________________________________Kung
mayroon man, ano ang mga iyon? ______________________________________________
__________________________________________________________________________
11) Anu-ano ang mga rason/dahilan bakit gusto mong ipasok at pag-aralin ang iyong anak
paaralang ito? ______________________________________________________________
__________________________________________________________________________
12) Anu-ano ang iyong mga inaasahan na matutuhan at malalaman ng iyong anak sa pagpasok
sa paaralang ito?____________________________________________________________
_________________________________________________________________________
13) Interesado ka bang dumalo sa study group meeting para lalong matuto tungkol sa
Montessori Approach Education at ECCCD _____________ ilang oras ba ang maari mong
ilaan? ____________________________________________________________________
14) Anonbg uri ng pakikipag-ugnay ang iyong inaasahan mula sa paaraln at sa iyong tahanan?
________________________________________________________________________
________________________________________________________________________
15) Anu-ano pang mga bagay ang iyong iminumungkahi para sa kabutihan ng iyong anak at
paaralan? ________________________________________________________________
EMERGENCY CONTACT: TELEPHONE/ADDRESS
Names
___________________________ ________________________________
___________________________ ________________________________

CHILD RECORD 4
 KASUNDUAN
Ako, kami si _________________________at ___________________________, mga
Magulang, tagapag-alaga ng batang si ___________________________________________
ay mangangakong susunod sa lahat ng alituntunin para sa mga pamilyang pinagkalooban ng
mga biyaya at amga karapatang ipasok sa Day Care Service Program sa pangangasiwa ng
City/Municipal Social Welfare and Development Office.
Ang mga sumusunod ay mga alituntuning nauukol sa mga magulang ng mga batang
sumali sa programa:
1. Nararapat na malinis ang katawan, ngipin at pananamit ng mga bata sa araw-araw
na pagpasok sa paaralan.

2. Kailangang dumalo sa mga pulong ukol sa mga magulang at guro minsan isang
buwan at kung mayroong di pangkaraniwang pangyayari o panayam.

3. Kailangang tumulong sa paglilinis sa silid-aralan, banyo at palikurang ginagamit ng

mga bata.

4. Kailangang tumulong sa pag-aalaga ng halaman sa paligid ng paaralan ayon sa

tungkuling itatakda ng guro.

5. Kailangang tumulong sa paghahanda ng pagkain ng mga batang nag-aaral at

maglilinis ng silid-aralan sa bawat paggamit (case to case basis)

6. Kailangang tumulong sa paggawa at pangangalaga ng mga kasangkapan,

kagamitan ng paaralan.

Sang-ayon:
____________________
Pirma ng ina

____________________ ____________________
Pirman ang Ama Pirma ng Day Care Teacher

____________________ ____________________
Petsa Pirma ng Day Care Supervisor

CHILD RECORD 5
 BIRTH CERTIFICATE

CHILD RECORD 6
 EARLY CHILDHOOD CARE & DEVELOPMENT CARD
CLINIC ______________________________________________ CHILD’S NO.
BARANGAY ______________________________________________
FAMILY NUMBER ______________________________________________
Sex: Male Female
CHILD’S NAME ______________________________________________
[ ] [ ]
MOTHER’S NAME ____________________________________________________________________
EDUCATIONAL LEVEL ____________________________________________________________________
OCCUPATION ___________________________________MONTHLY INCOME_________________
FATHER’S NAME ____________________________________________________________________
EDUCATIONAL LEVEL ____________________________________________________________________
OCCUPATION ___________________________________MONTHLY INCOME_________________
DATE FIRST SEEN BIRTHDATE BIRTH WEIGHT

PLACE OF DELIVERY BIRTH REGISTERED AT LOCAL

CIVIL REGISTRY (Date

COMPLETE ADDRESS OF FAMILY

House Number _______ Street __________Zone ______ Barangay _________________________,
BROTHER/S AND SISTER/S
NAME SEX DATE OF BIRTH

ESSENTIAL HEALTH AND NUTRITION SERVICES

DATE OF VISITS
1st 2nd 3rd 4th 5th 6th
NEW BORN SCREENING
BCG (at birth)
DPT (6 wks. 10 wks, 14 wks old)
OPV (6 wks. 10 wks, 14 wks old)
HEPATITIS B (6 wks. 10 wks, 14 wks old)
MEASLES (9 mos)
VITAMIN A (start at 6 mos.)
DEWORMING
DENTAL CHECK-UP

CHILD RECORD 7
 BCYW-DCS Form No. 5

INITIAL AND ANNUAL HEALTH RECORD

(For Use of the Physician)
I. Maternal History Please check illness/es during pregnancy
________ Goiter ________ German Measles
________ Diabetes ________ Hepatitis
________ Tuberculosis ________ Sexually Transmitted Disease
________ Heart Disease ________ Others (specify please)
II. Brief History
A. Type of Delivery
________ Normal Spontaneous Delivery
________ Caesarian Section
________ Force
B. Place of Delivery
________Hospital
________ Home
________ Others (Please Specify)
C. State Complications if any ________________________________________
_______________________________________________________________
D. Allergies, if any: _________________________________________________
_______________________________________________________________
III. Immunization: Dates Given
DPT ______________ ______________
POLIO ______________ ______________
BCG ______________ ______________
MEASLES ______________ ______________
IV. Deworming Dates of Last Deworming
_________ Yes ______________ ______________
_________ No ______________ ______________
V. Disability/Impairments: Please check if any:
___________ Congenital Deformities ___________Speech Defect
___________ Deafness ___________ Emotional Disturbances
___________ Others (Please Specify)
VI. Previous Illness Date
___________________________ ________________________
___________________________ ________________________
VII. Current Health Status
_____________________________________________________________________
_____________________________________________________________________
_____________________________________________________________________
VIII. Pertinent Physical Examination:
HEENT ________________________________
Chest/Lungs_____________________________
Abdomen_______________________________
GUT___________________________________
Muscular _______________________________
NEURO ________________________________
IX. Remarks
_____________________________________________________________________________________
_____________________________________________________________________________________
_____________________________________________________________________________________

____________________
Signature of Physician
____________________
Date

CHILD RECORD 8
 WEIGHT RECORD
Nutritional Status

Age in Months Weight

Normal Moderate Below Average

JUNE

JULY

AUGUST

SEPTEMBER

OCTOBER

NOVEMBER

DECEMBER

JANUARY

FEBRUARY

MARCH

Nutritional Status:
• Normal
• Moderate
• Below Average

CHILD RECORD 9
CHILD RECORD 10
Growth Monitoring Chart

CHILD RECORD 11
CHILD RECORD 12
CHILD RECORD 13
CHILD RECORD 14
GROSS MOTOR DOMAIN
ECC CHECK LIST
Gross Motor Present Comments
1st Eval. 2nd Eval. 3rd Eval.
1. Climbs on chair or other elevated piece of
furniture like a bed without help.
2. Walks backwards
3. Runs without tripping or falling
4. Walks downstairs, 2 feet on each step, with
one hand held
5. Walks upstairs holding onto a handrail, 2
feet on each step
6. Walks upstairs with alternate feet without
holding onto a handrail
7. Walks downstairs with alternate feet without
holding onto a handrail
8. Moves body part as directed
9. Jumps up
10. Throws ball overhead with direction
11. Hops 3 steps on preferred foot
12. Jumps and turns
13. Dances patterns/joins group movement
activities
TOTAL SCORE

FINE MOTOR DOMAIN

Gross Motor Present Comments
1st Eval. 2nd Eval. 3rd Eval.
1. Uses all 5 fingers to get food/tops placed
on a flat surface
2. Picks up objects with thumb & index finger
3. Displays a definite hand preference
4. Puts small objects in/out of containers
5. Holds crayon with all the fingers on his
hand as though making a fist (i.e. palmar
grasp)
6. Unscrews the lid of a container/unwraps
food
7. Scribbles spontaneously
8. Scribbles Vertical and horizontal lines
9. Draws circle purposefully
10. Draw a human figure (head, eyes, truck,
arms, hands/fingers)
11. Draw a house using geometric forms
TOTAL SCORE

CHILD RECORD 15
SOCIAL-EMOTIONAL DOMAIN
Gross Motor Present Comments
1st Eval. 2nd Eval. 3rd Eval.
1. Feeds self with finger foods (e.g. biscuits,
Bread) using fingers
2. Feeds using fingers to eat rice/viands with
spillage
3. Feeds self-using spoon with spillage
4. Feeds self-using fingers without spillage
5. Feeds self-using spoon without spillage
6. Eats without need for spoon feeding during
any meal
7. Helps hold cup for drinking
8. Drinks from cup with spillage
9. Drinks from cup unassisted
10. Gets drink for self unassited
11. Pours from pitcher without spillage
12. Prepares own food/snack
13. Prepares meals for younger siblings/family
members when no adult is around
Dressing Domain
14. Participates when being dressed (e.g. raise
arms or lifts leg)
15. Pulls down gartered shorts pants
16. Removes sando
17. Dresses without assistance except for
buttoning and tying
18. Dresses without assistance including
buttoning and tying
Toilet Training sub-domain
19. Informs the adult only after he has already
urinated (peed) or moved his bowels
(poohed) in his underpants
20. Informs the adult need to urinate (pee) or
move bowels (pooh-pooh) so he can be
brought to a designated place (e.g. CR)
21. Goes to the designated place to urinate
(pee) or move bowels (pooh) but
sometimes still does this in his underpants
22. Goes to the designated place to urinate
(pee) or move bowels (pooh) and never
does this in his underpants anymore
23. Wipes/cleans self after a bowel movement
(pooh)
24. Participates when bathing (e.g. rubbing
arms with soap)
25. Washes and dries hands without any help
26. Washes face without any help
27. Bathes without any help
TOTAL SCORE
CHILD RECORD 16
RECEPTIVE LANGUAGE DOMAIN
Gross Motor Present Comments
1st Eval. 2nd Eval. 3rd Eval.
1. Points to a 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 (e.g. in, on, under, etc.)
5. Follow 2-step instructions that include
simple prepositions
TOTAL SCORE

EXPRESSIVE LANGUAGE DOMAIN

Gross Motor Present Comments
1st Eval. 2nd Eval. 3rd Eval.
1. Uses 5 to 20 recognizable words
2. Uses pronouns (e.g. I, me, ako, akin)
3. Uses 2-to-3 word verb-noun combinations
(e.g.hingi, gatas)
4. Names objects in pictures
5. Speaks in grammatically correct 2-to-3
word sentences
6. Asks “what” questions
7. Asks “who” and “why” questions
8. Gives account of recent experiences (with
prompting) in order to occurrence using
past tense
TOTAL SCORE

CHILD RECORD 17
COGNITIVE DOMAIN
Gross Motor Present Comments
1st Eval. 2nd Eval. 3rd Eval.
1. Looks in the direction of a fallen object
2. Looks for a partially hidden object
3. Imitates behavior just seen a few minutes
earlier
4. Offers an object but may not release it
5. Looks for a completely hidden object
6. Exhibits simple “pretend” play (i.e. puts doll
to sleep)
7. Matches objects
8. Marches 2 to 3 colors
9. Matches pictures
10. Sorts based on shapes
11. Sorts objects based on attributes (e.g. size
and color)
12. Arranges objects according to size from
smallest to biggest
13. Names 4 to 6 colors
14. Copies shapes
15. Names 3 animals or vegetables when
asked
16. States what common household items are
used for
17. Can assemble simple puzzles
18. Demonstrates an understanding of
opposites by completing a statement (e.g.
Ang aso ay Malaki, ang daga ay _______?
19. Points to left and right sides of body
20. Can State what is silly or wrong with
pictures (e.g. Ano ang mal isa larawang
ito?)
21. Matches upper case letters; and matches
lower case laters
TOTAL SCORE

CHILD RECORD 18
SOCIAL-EMOTIONAL DOMAIN
Gross Motor Present Comments
1st Eval. 2nd Eval. 3rd Eval.
1. Enjoys watching activities of nearby people
or animals
2. Friendly with strangers but initially may
show slight anxiety or shyness
3. Plays alone but likes to be 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 cuddies toys
8. Demonstrates respect for elders using
terms like “po” and “opo”
9. Shares toys with others
10. Imitates adult activities (e.g. cooking,
washing)
11. Identifies feelings in others
12. Appropriately uses cultural gestures of
greeting without much prompting (e.g..,
mano, bless, kiss, etc.)
13. Comforts playmates/siblings in distress
14. Persists when faced with a problem or
obstacles to his wants
15. Helps with family chores (e.g., wiping
tables, watering plants, etc.
16. Curious about environment but knows when
to stop asking questions of adults
17. Waits for his turn
18. Asks permissions to play with toy being
used by another
19. Defends possessions with determination
20. Plays organized group games fairly (e.g.,
does not cheat to win)
21. Can talk about complex feelings (e.g..,
anger, sadness, worry) he experiences
22. Honors a simple bargain with caregiver
(e.g., plays outside only after cleaning/fixing
his/her room)
23. Watches responsively over younger
siblings/family members
24. Cooperates with adults and peers in group
situations to minimize quarrels and conflicts
TOTAL SCORE

CHILD RECORD 19
Transfer the raw for each domain to the table below. Using the Scaled Score
Equivalent of Raw Scores Table, convert the raw scores, add the Scaled Scores
across all domains. To derive the Standard Score, refer to the Standard Score
Equivalent of Sums of Scaled Score Table. Write the Child’s age on each
evaluation.

A G E
1st Eval. Date: _________ 2st Eval. Date: _________ 3st Eval. Date: _________
Domain Child’s Age: __________ Child’s Age: __________ Child’s Age: __________

Gross Motor
Fine Motor
Self-Help
Receptive Language
Expressive Language
Cognitive
Social-Emotional
Sum of Scaled Scores

Standard Score

Interpretation

Interpretation of Scaled Score: Interpretation of Standard Score:

Scaled Score Interpretation Scaled Score Interpretation
Development in the domain Overall development must be
1-3 must be monitored after 3 67 and below monitored after 3 months
months
Development in the domain Overall development must be
4-6 must be monitored after 6 70-79 monitored
months
Average overall development Average overall development
7-13 80-119
in the domain
Suggests slightly advanced Slightly advance overall
14-16 120-129
development in the domain
Suggest highly advanced Highly advance overall
17-19 130 and above
development in the domain development

CHILD RECORD 20
CHILD RECORD 21
CHILD RECORD 22
CHARACTER TRAITS
1. Love of God – demonstrates love of God,
parents, elders and other
2. Love of Country – demonstrates love and pride
of one’s country
3. Respect for Parents, Elders, and Others –
demonstrates love for parents, elders and
others.
4. Courtesy and Politeness-be able to gesture that
show respect for others.
5. Appreciation of One’s Culture – exhibits love of
Filipino Culture.
6. Social Responsibility – demonstrates cares and
concern for others.
7. Love of Work – demonstrates proper use of
one’s resource.
8. Sportsmanship – displays good conduct in
times of victory and defeat in any kind of
competition.
9. Cleanliness and Orderliness – demonstrates
proper ways of good grooming and tidiness.
10. Care of One’s surroundings – demonstrates
concern for a clean and orderly dwelling place.
11. Care of Environment – practices conservation
of environment through proper care of living
things.
12. Thriftiness – practices wise use and
conservations of one’s resources.
13. Promptness – demonstrates the value of time.
14. Self Respect - manifests respect, control for
and deeds that are true and worthy.
15. Honesty and Truthfulness – exhibits words
and deeds that are true and worthy.
16. Responsibility – manifests respect, control for
and discipline for oneself.

CHILD RECORD 23
 ONE-ON-ONE CONFERENCE
with the PARENT

__________________________________
Parent’s Signature over Printed Name

__________________________________
Parent’s Signature over Printed Name

CHILD RECORD 24
ONE-ON-ONE CONFERENCE
with the PARENT

__________________________________
Parent’s Signature over Printed Name

__________________________________
Parent’s Signature over Printed Name

CHILD RECORD 25
 CHILDREN’S NARRATIVE
PROGRESS REPORT

CHILD RECORD 26
 HOME VISITATION
OBSERVATION/RECORDS OF
DATE PARENT’S INFORMATION ACTIVITIES UNDERTAKEN/REMARKS
CHILD’S BEHAVIOR
CHILD RECORD 27
OBSERVATION
NOTE

CHILD RECORD