T.R.

YANGCO CATHOLIC
EDUACATIONAL
INSTITUTE, INC
Delos Reyes Street, San Juan,
San Antonio, Zambales
S.Y. 2022-2023

Sociodemographic Profile
Indicate the complete sociodemographic profile of the child.

Child’s Name: Sex: Date of Birth:

month day year

Address:
Barangay Municipality/City Province Region

Child’s Handedness (Check appropriate Box) right left

both not yet established Is
the child presently studying? (Check appropriate Box) Yes No
If Yes, write name of child’s school / learning center / day care:
Father’s Name: Fathers Age:
Father’s Occupation: Father’s Educational Attainment:
Mother’s Name: Mother’s Age:
Mother’s Occupation: Mother’s Educational Attainment:
Child’s Number of Siblings Child’s Birth Order (1st, 2nd, 3rd, etc.):
(Brother/s and Sister/s):

Early Childhood Care and Development (ECCD) Checklist, Child’s Record 2 1

 It is recommended that the Checklist be administered to the child once a year.

Computation of the Child’s Age

After verifying the dates, compute the child’s age by subtracting the date he was born from the date the test was administered.
Each month is composed of 30 days. Do not round off the months or years. Write the examiner’s name each time the
test is administered.

Year Month Day Examiner’s Name

1st
Date Tested
Child’s Date of Birth
assessment Child’s Age

2n
Date Tested
Child’s Date of Birth
Child’s Age

d
assessment

3r
Date Tested
Child’s Date of Birth
Child’s Age

d
assessment

MS. FLORA F. FERNADEZ

ADVISER

MR. JAYSON O. DELGADO, MA CDDS

SCHOOL PRINCIPAL
 Introducing the Checklist
Introduce the Checklist to the parent/caregiver by saying the following:

We are here to help you find out how your child is developing by asking you some questions about
the things he is able to do, or by having your child do some activities. There is no pass or fail
score. This is just a checklist. Some of the questions are for children older than your child so I
do not expect him to be able to do all the things I will be asking.

We plan to administer this Checklist several times until your child is 6 years old. So please do
not teach or coach him because we need to know just what he can and cannot do at this age.

Later on we will share the results with you and give suggestions on what else you can do to
stimulate your child’s development.

After rapport has been established, introduce the Checklist to the child by saying the following:

I will be asking you to do some things for me today. Some of them will be very easy. Some of
them may be a little hard for you. Do not worry if you cannot do them all because some of the
activities are for children who are a little older than you. So I do not expect you to be able to
do everything I ask. Just try your best.

How to Administer
This form can be used for three separate evaluations of the same child so it will be easy for you to
see how he is developing as he grows older. The “Present” portion of this Record has three columns
where you are to mark the childs skill’s and behavior each time you assess him. If the child exhibits
the skill or behavior, put a check (✔) in the designated column. If the child does not, put a
hypen (-) and write additional information in the “Comments” column explaining why the
child was unable to demonstrate the behavior.

Where to start and stop

Administer all the items.

How to score
Tally the number of check marks (✔) in each domain and record this in the section labeled
“Total Score.”
 Gross Motor Domain
Gross Motor Material/Procedure Present Comments
nd rd
1 Eval 2 Eval 3 Eval
st

1. Climbs on chair or other Parental report will suffice.

elevated piece of furniture
like a bed without help

2. Walks backwards MATERIAL: toy

PROCEDURE:
Ask the child to walk backwards by demonstrating this.
Credit if the child is able to walk backwards without
falling and holding on to anything. Parental report
will suffice.

3. Runs without tripping or MATERIAL: ball

falling PROCEDURE:
Encourage the child to run by rolling a ball across the floor.
Credit if the child can run fast and smoothly without
tripping or falling.

4. Walks down stairs, two Parental report will suffice.

feet on each step, with
one hand held

5. Walks upstairs holding MATERIAL: toy

onto a handrail, two feet PROCEDURE:
on each step Place a toy in the middle of the step and ask the child to walk
up the stairs to get the toy. Credit if the child walks up the
stairs using the handrail or wall for support and places
both feet on each step before stepping on the next one.
Parental report will suffice.

6. Walks upstairs with MATERIAL: toy

alternate feet without PROCEDURE:
holding onto a handrail Place a toy in the middle of the step and ask the child to walk
upstairs to get the toy. Credit if the child walks upstairs,
alternating his feet as he steps on each successive step
without holding on to the handrail or wall for support.
Parental report will suffice.

7. Walks downstairs with MATERIALS: toy

alternate feet without PROCEDURE:
holding onto a handrail Place a toy in the middle of the step and ask the child to walk
downstairs to get the toy. Credit if the child walks down-
stairs, alternating his feet as he steps on each successive
step without holding onto the handrail or wall for
support. Do not give credit if the child places both feet on
the step or uses the handrail or wall for support.
Parental report will suffice.

8. Moves body part PROCEDURE:

as directed Ask the child to raise both arms.

9. Jumps up This must be elicited by the interviewer.

Gross Motor Material/Procedure Present Comments

 1st Eval 2nd Eval 3rd Eval
10. Throws ball overhead with MATERIAL: ball
direction PROCEDURE:
Give the child the ball and stand at least 3 feet away from
him. Ask the child to throw the ball to you using an
overhand throw. You may show the child how to do it.
Credit if the child throws the ball within your arm’s
reach between your knees and head using an
overhand throw and not sideways or underhand.

11. Hops one to three steps on PROCEDURE:

preferred foot Ask the child to lift his foot and hop at least three times
on his preferred foot. Credit if the child is able to hop
at least three times on his preferred foot without
holding on to anything.

12. Jumps and turns PROCEDURE:

Ask the child to jump while making a half-turn. Credit if
the child is able to do this without tripping or falling.

13. Dances patterns/joins Parental report will suffice.

group movement activities

TOTAL SCORE
 Fine Motor Domain
Fine Motor Material/Procedure Present Comments
nd rd
1 Eval 2 Eval 3 Eval
st

1. Uses all five fingers to get MATERIAL: small toy /object

food/toys placed on a flat PROCEDURE:
surface Seat the child on the parent’s lap with his elbows at level with
the tabletop and his hands on the table or flat surface. Drop
a small toy in front of him and attract his attention by
pointing to the toy or tapping the table/flat surface. Credit if
the child picks up the toy, using all five fingers as if
raking.

2. Picks up objects with MATERIAL: any small toy or food

thumb and index finger PROCEDURE:
Place a toy/food in front of the child and within his reach.
Attract his attention by tapping near the toy/food. Credit if
the child uses the tips of his thumb and index or
forefinger to pick up the toy/food.

3. Displays a definite hand MATERIAL: toy

preference PROCEDURE:
Place the toy directly in front of the child at midline (not to
his left or his right) and ask him to reach for this. Credit
if he uses the same hand two out of three times.
Parental report will suffice.

4. Puts small objects in/out MATERIALS: small objects, container

of containers This must be elicited by the interviewer.

5. Holds crayon with all the MATERIAL: crayon

fingers of his hand PROCEDURE:
making a fist (i.e., palmar Present the child with a crayon and have him get this.
grasp) Credit if he holds it by wrapping all five fingers around as if
making a fist. Automatically credit this item if he uses the
tips of all five fingers or his thumb, index, and middle
fingers.
This must be elicited by the interviewer.
6. Unscrews the lid of a MATERIALS: container with screw-on top or wrapped candy.
container or unwraps This must be elicited by the interviewer.
food

7. Scribbles spontaneously MATERIALS: paper, pencil/crayon

PROCEDURE:
Place a paper and pencil/crayon on the table or flat surface
and ask the child to draw anything he wants without
showing him what to do. Credit if the child uses the
tips of his thumb and any of his other fingertips to
grasp the pencil/crayon and makes purposeful marks on
the paper (not accidental marks).
 Fine Motor Material/Procedure Present Comments
nd rd
1 Eval 2 Eval 3 Eval
st

8. Scribbles vertical and MATERIALS: paper, pencil/crayon

horizontal lines PROCEDURE:
Place a piece paper and pencil/crayon on the table or flat
surface and ask the child to draw vertical and horizontal
lines after you have demonstrated these to him. Credit if the
child produces a vertical or horizontal line that is at
least 2 inches long and does not deviate or vary from
your vertical line by more than 30 degrees. The lines may
be wavy but not broken.

9. Draws circle purposefully MATERIALS: paper, pencil/crayon

PROCEDURE:
Place a paper and pencil/crayon on the table or flat surface
and ask the child to draw a circle or a ball after you have
demonstrated it to him. Credit if the child produces any
curve that is closed or nearly closed. Continuous spiral
motions are not credited.

10. Draws a human figure MATERIALS: paper, pencil

(head, eyes, trunk, arms, PROCEDURE:
hands/fingers) Give the child a pencil and a paper and ask him to draw a
picture of a person. Credit if the child has drawn three or
more body parts. A pair is considered one part (eyes, ears,
arms, hands, legs, and feet) and must be drawn in
pairs to get full credit unless the drawing is in
profile.
11. Draws a house using
geometric forms MATERIALS: paper, pencil
PROCEDURE:
Give the child a pencil and paper and ask him to draw a
picture of a house. Credit if the child has drawn at least
the roof, main frame, and a door or window.

TOTAL SCORE
 Self-Help Domain
Self-Help Material/Procedure Present Comments
Feeding sub-domain 1st Eval 2nd Eval 3rd Eval

1. Feeds self with finger MATERIALS: bread, biscuits

food (e.g. biscuits, This must be elicited by the interviewer.
bread) using fingers

2. Feeds self using fingers to Parental report will suffice.

eat rice/viands with
spillage

3. Feeds self using spoon Parental report will suffice.

with spillage

4. Feeds self using fingers Parental report will suffice.

without spillage

5. Feeds self using spoon Parental report will suffice.

without spillage

6. Eats without need for Parental report will suffice.

spoonfeeding during any
meal

7. Helps hold cup for Note: The cup should not have a lid or spout.
drinking

8. Drinks from cup with Ask the caregiver if the child can drink from a cup/glass
spillage with some spillage. The cup should not have a lid or
spout.
9. Drinks from cup MATERIALS: drinking cup, water
unassisted This must be elicited by the interviewer.

10. Gets drink for self Parental report will suffice.

unassisted

11. Pours from pitcher Parental report will suffice.

without spillage

12. Prepares own food/snack Ask the caregiver if the child can prepare his own snack
without help except for getting items that are hard to reach
(e.g., bowl spoon).

13. Prepares meals for Parental report will suffice.

younger siblings/family
members when no adult
is around

Dressing sub-domain

14. Participates when being Parental report will suffice.

dressed (e.g., raises arms
or lifts leg)

15. Pulls down gartered short Parental report will suffice.

pants

16. Removes sando Parental report will suffice.

Self-Help Material/Procedure Present Comments

 1st Eval 2nd Eval 3rd Eval
17. Dresses without Material: small shirt w/button and shoestring
assistance except for Parental report will suffice.
buttons and tying

18. Dresses without PROCEDURE:

assistance including Have the child demonstrate how to button and tie to credit
buttons and tying this item.

Toilet Training
sub-domain

19. Informs the adult only Parental report will suffice.

after he has already
urinated (peed) or
moved his bowels
(poohed) in his
underpants

20. Informs the adult of need Parental report will suffice.

to urinate (pee) or move
bowels (pooh-pooh) so
he can be brought to a
designated place (e.g.,
comfort room)

21. Goes to the designated Parental report will suffice.

place to urinate (pee) or
move bowels (pooh) but
sometimes still does this
in his underpants

22. Goes to the designated Parental report will suffice.

place to urinate (pee) or
move bowels
(pooh) and never does
this in his
underpants/ wear
anymore
23. Wipes/cleans self after a Parental report will suffice.
bowel movement (pooh)

Bathing sub-domain

24. Participates when bathing Parental report will suffice.

(e.g., rubbing arms with
soap)

25. Washes and dries hands Ask the caregiver if the child can wash and dry his hands
without any help without any help or supervision except to turn on/off
faucets that are out of reach.

26. Washes face without any Ask the caregiver if the child can wash and dry his
help face without any help or supervision except to turn
on/off faucets that are out of reach.

27. Bathes without any help Parental report will suffice.

TOTAL SCORE
 Receptive Language Domain
Receptive Language Material/Procedure Present Comments
nd rd
1 Eval 2 Eval 3 Eval
st

1. Points to a family PROCEDURE:

member when asked to Ask the child to point to his mother/caregiver. Credit if he
do so does so.

2. Points to five body parts PROCEDURE:

on himself when asked to Have the child point to his eyes, nose, mouth, hands and
do so feet or other body part. Credit if he can point to all
these.
3. Points to five named MATERIAL: picture book 1
pictured objects when PROCEDURE:
asked to do so Show the child a picture book (one picture per page) and
ask him to point to the picture by saying, “Where’s the
?” Credit if the child can use his finger to
point to at least five pictures.

4. Follows one-step MATERIAL: block/toy

instructions that include PROCEDURE:
simple prepositions (e.g., Ask the child to put a block/toy under the table; on the table;
in, on, under, etc.) in the bag. Do not point or use gestures when giving the
instructions. Credit if the child is able to follow at least
one of the instructions.

5. Follows two-step MATERIAL: block/toy

instructions that include PROCEDURE:
simple prepositions Ask the child to get a block/toy from under the table and
then place it on the table. Do not point or use gestures when
giving the instruction. Credit if the child is able to follow.

TOTAL SCORE
 Expressive Language Domain
Expressive Language Material/Procedure Present Comments
nd rd
1 Eval 2 Eval 3 Eval
st

1. Uses five to 20 PROCEDURE:

recognizable words Ask the caregiver if the child can clearly say five to six words
aside from mama and papa. This will be the minimum
number.

2. Uses pronouns (e.g. I, Parental report will suffice.

me, ako, akin)

3. Uses two- to three-word Parental report will suffice.

verb-noun combinations
(e.g., hingi gatas)

4. Names objects in pictures MATERIAL: picture book 2

PROCEDURE:
Show the child a picture book, point to an object in the
book, then ask him to name it (e.g., “Ano ‘to?”). Credit if
the child can say the correct name of at least four
objects.

5. Speaks in grammatically Parental report will suffice.

correct two- to three-
word sentences

6. Asks “what” questions Parental report will suffice.

7. Asks “who” and “why “ Parental report will suffice.

questions

8. Gives account of recent PROCEDURE: Ask the caregiver if the child can recount
experiences (with recent experiences in correct sequence and using past tenses
prompting) in order of correctly. The caregiver can prompt him so he can complete
occurrence using past what he is talking about (e.g., Tapos ano pang nangyari?).
tense Parental report will suffice.

TOTAL SCORE
 Cognitive Domain

Cognitive Material/Procedure Present Comments

nd rd
1 Eval 2 Eval 3 Eval
st

1. Looks in the direction of MATERIAL: spoon/ball

fallen object PROCEDURE:
With the child seated, get his attention and drop a spoon/
ball in front of him. Then observe if his eyes look down as it
falls. Credit if the child can bring his eyes and head down
as the object falls.

2. Looks for a partially MATERIALS: ball, small towel/cloth

hidden object PROCEDURE:
With the child facing you, partially hide a ball behind a
small towel and observe if he will look for it and find it.
Credit if the child pulls the towel and gets the hidden
ball.
3. Imitates behavior just Parental report will suffice.
seen a few minutes
earlier
4. Offers an object but will Parental report will suffice.
not release it

5. Looks for a completely MATERIALS: ball, small towel/cloth

hidden object PROCEDURE:
With the child facing you, hide a ball completely under a
small towel and observe if he will look under the towel.
Credit if he looks under the towel and gets the hidden
ball.

6. Exhibits simple “pretend” MATERIALS: doll or toy car/block

play (feeds, put doll to PROCEDURE:
sleep) If the child is a girl, carry the doll and try to rock it to sleep.
If the child is a boy, move the toy car/block back and forth.
Credit if the child can imitate this.

7. Matches objects MATERIALS: pairs of spoons, balls, blocks

PROCEDURE:
Place one spoon, one ball, and one block on the table. Give
the child the other set of objects arranged in random order.
Demonstrate a matching response (e.g., spoon to spoon)
then return the objects to the child. Say, “Put each object on
the one that is just like it.” Credit if the child can match
the objects correctly.

8. Matches two to three MATERIALS: Three pairs of crayons (blue, red, yellow)
colors PROCEDURE:
Place one crayon of each color on the table or flat
surface. Give the child the other crayons arranged in
random order. Demonstrate a matching response (e.g.,
red crayon with another red crayon) then return the crayons
to the child. Say, “Put each crayon on the one that is just like
it.” Credit if the child can match all colors correctly.
 Cognitive Material/Procedure Present Comments
nd rd
1 Eval 2 Eval 3 Eval
st

9. Matches pictures MATERIALS: Three pairs of picture cards (e.g., pictures of an

apple, orange, banana)
PROCEDURE:
Place one copy of each picture on the table or flat surface.
Give the child the other pictures arranged in random order.
Demonstrate a matching response (e.g., picture of an apple
with another apple) then return the pictures to the child. Say,
“Put each picture on the one that is just like it.” Credit if the
child can match all the pictures correctly.

10. Sorts based on shapes MATERIALS: Four pairs of different shapes that are of the
same size and color.
PROCEDURE:
Show the child the shapes. Tell the child, “Put together the
ones that are the same.” After the child sorts and groups the
shapes, point to the ones with the same shape and ask, “Why
did you put these together?” Credit if the child can group
the same shapes and say why they are the same (pareho
sila, pareho sila ng hugis/shape, puro sila bilog).

11. Sorts objects based on MATERIALS: Four pairs of the same shape that differ in size
two attributes (e.g., and color.
size and color) PROCEDURE:
Show the child the shapes. Tell the child, “Put together
the ones that are the same”. Credit if the child can sort
all the shapes according to size and color.

12. Arranges objects MATERIALS: Four pieces of graduated squares and four
according to size pieces of graduated sized circles
from smallest to PROCEDURE:
biggest Show the child the first set of squares spread out at random
on a table or flat surface. Say, “Here are 4 squares. Look,
I can begin with the smallest, then the next big one, until
the biggest one.” Demonstrate how to arrange the squares.
Then disarrange these and tell the child, “Now you start with
the smallest, put the next one and the next big one until the
last one.”
Repeat this procedure using the circles without
demonstrating.
Credit if the child arranges at least one set of shapes in
correct order from smallest to biggest. Allow one trial for
each set of shapes.

13. Names four to six colors MATERIALS: Six papers of different colors
PROCEDURE:
Ask the child, “What color is this?” Credit if the child can
name four to six colors correctly.

14. Copies shapes MATERIALS: paper and pen/crayon

PROCEDURE:
Let the child copy a circle, triangle, and square after
demonstrating how each of this is done.
 Cognitive Material/Procedure Present Comments
nd rd
1 Eval 2 Eval 3 Eval
st

15. Names 3 animals or Credit if the child can name 3 animals or vegetables
vegetables when
asked
16. States what common Credit if he can state the use or function of at least two
household items are used household items like a bed and a drinking glass.
for

17. Can assemble simple MATERIAL: Simple four- to six-piece puzzles

puzzles Procedure: Allow the child to solve the puzzle in 2
minutes. Proceed to the next item after 2 minutes.
18. Demonstrates an Parental report will suffice.
understanding of
opposites by completing a
statement (e.g., Ang aso
ay malaki, ang daga ay
.”)

19. Points to left and PROCEDURE:

right sides of body Sit across the child and ask “Show me your left hand.” Do
the same for the following:
Right hand, left foot, right knee, left shoulder, right eye,
right knee, left leg. Credit if the child can correctly
point out the left and right side on at least five body
parts as
requested.

20. Can state what is silly MATERIALS: Two picture cards depicting activities that have
or wrong with pictures something silly or wrong with them.
(e.g., Ano ang mali sa PROCEDURE:
larawang ito?) Show the pictured scenes to the child one at a time and ask,
“What is wrong with this picture?” Credit if the child
correctly identifies what made the picture incorrect.

21. Matches upper case MATERIALS: 2 sets of alphabet cards with upper and lower
letters; and matches lower case letters.
case letters PROCEDURE:
Randomly present 4 pairs of upper case letters. Have the
child match these.
Do the same with 4 pairs of lower case letters.
Credit if the child can match any 4 pairs, regardless of
whether these are upper or lower case.
Note: The child does not have to know the name of the
letters

TOTAL SCORE
 Social-Emotional Domain
Social-Emotional Material/Procedure Present Comments
nd rd
1 Eval 2 Eval 3 Eval
st

1. Enjoys watching activities Parental report will suffice.

of nearby people or
animals

2. Friendly with Parental report will suffice.

strangers but initially
may show slight
anxiety or shyness
3. Plays alone but likes to Parental report will suffice.
be near familiar adults
or brothers and sisters

4. Laughs or squeals Parental report will suffice.

aloud in play

5. Plays peek-a-boo Parental report will suffice.

(bulaga)

6. Rolls ball interactively Parental report will suffice.

with caregiver/examiner

7. Hugs or cuddles toys Parental report will suffice.

8. Demonstrates respect for Parental report will suffice.

elders using terms like
“po” and “opo”

9. Shares toys with others Parental report will suffice.

10. Imitates adult Parental report will suffice.

activities (e.g., cooking,
washing)
11. Identifies feelings in Credit if the child can tell when the caregiver is feeling
others happy, sad, worried, etc. Parental report will suffice.

12. Appropriately uses Parental report will suffice.

cultural gestures of
greeting without much
prompting (e.g., mano,
bless, kiss, etc.)

13. Comforts playmates/ Parental report will suffice.

siblings in
distress
14. Persists when faced with a Credit if the child tries to solve the problem instead
problem or obstacle to of crying when something stands in the way of what he
his wants wants (e.g., fastening a box of his treasures with a
string if the lid no longer closes)

Parental report will suffice.

 Social-Emotional Material/Procedure Present Comments
nd rd
1 Eval 2 Eval 3 Eval
st

15. Helps with family chores Parental report will suffice.

(e.g., wiping tables,
watering plants, etc.)

16. Curious about Credit if the child asks questions about things around him
environment but knows but knows when he is being “makulit” about the topic.
when to stop asking
questions of adults

17. Waits for his turn Parental report will suffice.

18. Asks permission to play Parental report will suffice.

with toy being used by
another

19. Defends possessions Parental report will suffice.

with determination Credit if the child tries to hold on to what is his when
someone tries to grab this from him.

20. Plays organized group Parental report will suffice.

games fairly (e.g., does
not cheat to win)

21. Can talk about complex Parental report will suffice.

feelings (e.g., anger,
sadness, worry) he
experiences

22. Honors a simple bargain Parental report will suffice.

with caregiver (e.g.,
plays outside only
after cleaning/fixing
his/her room)

23. Watches responsibly over Parental report will suffice.

younger siblings/family
members

24. Cooperates with adults Parental report will suffice.

and peers in group
situations to minimize
quarrels and conflicts

TOTAL SCORE
Name of examiner :
Date administered :
Place where test is administered :

To the examiner :
Please fill out the spaces below for additional information. Thank you very much.
Write down your notes, descriptions and observations on the following points:

Child’s background (ex. behavior/health/etc.)

Family environment (ex. Health of family members/family problems/ economic conditions/etc.)

Parents’ stimulating activities for the child (What are the activities/things that the parents do to help stimulate the child’s
develop- ment?)

Home environment (ex. Facilities/type of house/ household items/interaction/etc.)

Others
Transfer the raw score for each domain in the table below. Using the Scaled Score Equivalent of Raw Scores Table, convert the raw
scores to Scaled Scores appropriate to the age of the child. To arrive at the Sum of Scaled Scores, add the Scaled Scores across all
domains. To derive the Standard Score, refer to the Standard Score Equivalent of Sums of Scaled Scores Table. Write the
Child’s age on each evaluation.

Age
Domain 2 Evaluation Date:
nd
1 Evaluation
st
Date: 3rd Evaluation Date:

Child’s Age Child’s Age Child’s Age

Raw Score Scaled Score Raw Score Scaled Score Raw Score Scaled Score

Gross Motor
Fine Motor
Self-Help
Receptive Language
Expressive Language
Cognitive
Social- Emotional
Sum of Scaled Scores
Standard Score
Interpretation
 Scaled Scores
Mark an x on the dot corresponding to the Scaled Score for each domain and connect the x’s. Write the child’s age on
each evaluation.

Child’s Age: Child’s Age: Child’s Age:

DOMAIN DOMAIN DOMAIN

EXPRESSIVE LANGUAGE

EXPRESSIVE LANGUAGE
EXPRESSIVE LANGUAGE
RECEPTIVE LANGUAGE

RECEPTIVE LANGUAGE
RECEPTIVE LANGUAGE
SOCIAL-EMOTIONAL

SOCIAL-EMOTIONAL
SOCIAL-EMOTIONAL
SCALED SCORE

SCALED SCORE
SCALED SCORE
GROSS MOTOR

GROSS MOTOR
GROSS MOTOR
FINE MOTOR

FINE MOTOR
FINE MOTOR
COGNITIVE

COGNITIVE
COGNITIVE
SELF-HELP

SELF-HELP
SELF-HELP
Suggests advanced development

19 • • • • • • • 19 • • • • • • • 19 • • • • • • •

18 • • • • • • • 18 • • • • • • • 18 • • • • • • •

17 • • • • • • • 17 • • • • • • • 17 • • • • • • •

16 • • • • • • • 16 • • • • • • • 16 • • • • • • •

15 • • • • • • • 15 • • • • • • • 15 • • • • • • •

14 • • • • • • • 14 • • • • • • • 14 • • • • • • •

13 • • • • • • • 13 • • • • • • • 13 • • • • • • •

12 • • • • • • • 12 • • • • • • • 12 • • • • • • •
Average development

11 • • • • • • • 11 • • • • • • • 11 • • • • • • •

10 • • • • • • • 10 • • • • • • • 10 • • • • • • •

9 • • • • • • • 9 • • • • • • • 9 • • • • • • •

8 • • • • • • • 8 • • • • • • • 8 • • • • • • •

7 • • • • • • • 7 • • • • • • • 7 • • • • • • •

6 • • • • • • • 6 • • • • • • • 6 • • • • • • •
Re-test after 3- 6 months

5 • • • • • • • 5 • • • • • • • 5 • • • • • • •

4 • • • • • • • 4 • • • • • • • 4 • • • • • • •

3 • • • • • • • 3 • • • • • • • 3 • • • • • • •

2 • • • • • • • 2 • • • • • • • 2 • • • • • • •

1 • • • • • • • 1 • • • • • • • 1 • • • • • • •
First Printing

NOT FOR SALE

January 2004
Manila, Philippines

Standard Scores
Mark an x on the corresponding standard score for each test administration and connect the x’s. Write the date for each test administration.

AGES
3 years & 1 month 4 years 5 years
160
Suggests advanced

150
development

140

130

120
Average development

110

100

90

80

70
Re-test after 3 to 6 months

60

50

40

30

20

Date Tested