Early Childhood Care and Development Council
FORM 1.A FATHER’S PROFILE
1. Personal Information
Last Name First Name Middle Initial Date of Birth Age
2. Civil Status
Single Married Separated Widow Live-in
3. Address
District ______________________________________________________________ Purok/Zone _________________
4. Mother Tongue
Tagalog Visayan Ilocano Bicolnon
Others, please specify ____________________________________________
5. Other dialects Spoken at home, please specify _____________________________________________
6. Educational Attainment
Elem./Graduate High School/ Graduate College/ Graduate
Technical/ Vocational Graduate Masteral Unit/Degree Doctoral Unit/ Degree
7. Occupational Status
Retired
Employed Unemployed
OFW Others, please specify ________________________________________
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Early Childhood Care and Development Council
FORM 1.B MOTHER’S PROFILE
1. Personal Information
Last Name First Name Middle Initial Date of Birth Age
Address
District ______________________________________________________________ Purok/Zone _________________
2. Pregnant?
Yes No
3. Civil Status
Single Married Separated Widow Live-in
4. Mother Tongue
Tagalog Visayan Ilocano Bicolnon
Others, please specify ______________________________________________
5. Other dialects Spoken at home, please specify _____________________________________________
6. Educational Attainment
High School/ Graduate College/ Graduate
Elem./ Graduate
Technical/ Vocational Graduate Masteral Unit/ Degree Doctoral Unit/ Degree
7. Occupational Status
Employed Unemployed Retired
OFW
8. At what age Others,
are you interested to put your child in a Day Careplease
Centerspecify ________________________________
4 years old
Below 3 years old 3 years old
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Early Childhood Care and Development Council
FORM 1. C FAMILY PROFILE
A. Home Profile
1. Ownership
Owned Rented With parents With relatives
2. Materials
Nipa Wood Concrete Make Shift
3. Nature
_____________________ One Room Multiple Rooms
With Toilet With Toilet With bedroom
Without Toilet Without Toilet With dining room
With open play area With open play area With sala
Without open play area Without open play area With kitchen
4. Utilities and Appliances
With mobile phone With CD/DVD player
With running water
With Electricity With computer With Television
With internet With radio
With Aircon
5. Learning and Recreation/ Fun & Games
Books Board Games
Magazines/ comics
Newspaper Story/ picture books Puzzles
Pets Toys
6. Persons Staying in the Same Household
Relatives Non-Relatives
Immediate Family Member
(Father, Mother, Siblings) (Aunts, Uncles, Cousins, (Household help/Nanny)
Grandparents, Nieces)
Name and Signature of CDT: ________________________________________________
Date Conducted: __________________________________________________________________________
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Early Childhood Care and Development Council
FORM 2 – CHILDREN’S PROFILE
1. Personal Information
Last Name First Name Middle Initial Date of Birth Age
2. Sex
Male Female
3. Birth Order _____________________
4. Registered
Yes No
5. Born at
Hospital Health Center Home
6. Mother Tongue
Tagalog Visayan Ilocano Bicolnon
Others, please specify _________________________________________________________
7. Other dialects spoken at home. Please specify _________________________________________________________
8. Height (cm) ___________________________________
9. Weight (kg) ___________________________________
10. Does the Child have:
Others pls. specify ___________
ECCD Mother and Child book
11. Vaccination andCard
Other Health Data
BCG Yes No Don’t Know
DPT Yes No Don’t Know
Oral Polio Yes No Don’t Know
Hepa B Yes No Don’t Know
Measles Yes No Don’t Know
Others Yes No Don’t Know
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Early Childhood Care and Development Council
12. Physical Attributes
12. 1 Physical Deformity
Hare Lip Cross-Eyed (Duling or Banlag) Deaf Blind
Disabled leg Disabled Arm/ Hand Deformity in Fingers/ Toes
12.2 Problems with:
Speaking Hearing Vision
Behavior
12. 3 Left-Handed
Yes No
13. Siblings
Age Education: In School or Out of School
In School Out of School
Male Female
14. Prior Early Childhood Experience
14.1 Nursery
Private Pre- School Private Day Care Church-Based Others
Public Pre-School Public Day Care Home-Based
14.2 Kindergarten
Private Pre- School Private Day Care Church-Based Others
Public Pre-School Public Day Care Home-Based
14. 3 Preparatory
Private Pre- School Private Day Care Church-Based Others
Public Pre-School Public Day Care Home-Based
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Early Childhood Care and Development Council
15. Other Performances Related Inputs
15.1 Learns at Home with
Nobody Siblings House Help/Maid Tutor
Mother/Father/Both Relatives Others
15.2 Play/ Interacts with Older Siblings
Always Sometimes Rarely Never
15.3 Play/Interact with Younger Siblings
Always Sometimes Rarely Never
15.4 Play/ Interacts with Neighbors of Same Age
Always Sometimes Rarely Never
16. Logistics
16.1 Has Meal Before Going to School
Always Most of the time Sometime Rarely Never
16.2 Food Normally Eaten by Child
Vegetables Pork Chicken Beef Fish
Rice Noodles Soup Bread Fruits
Cereals Fruit Juice Milk
16.3 Has Baon
Money Food Both None Don’t Know
16.4 Travel Time from Home to DCC (mins) _____________________
16.4.1. Mode
Walking Private Vehicle Public Transportation
16.5 Travel Time from Home to DCC (mins) _____________________
16.5.1. Mode
Walking Private Vehicle Public Transportation
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Early Childhood Care and Development Council
FORM 3- COMMUNITY PROFILE
Name of Barangay ___________________________________________
1. Total Population ___________________________________________
2. Number of Households _____________________________________
3. Number of Children 0-4 Years old ____________________________
< 1 year old _________
1 year old __________
2 years old _________
3 years old _________
4 years old _________
4. Population Density
Very Crowded Moderately Crowded Not Crowded
Has Lots of Open/Green Areas
5. Public Services
With Day Care Center With Barangay Health Center/Clinic
With ECCD Center With Playground/Park
6. Health and Safety Conditions
Clean Has Uncollected Trash Has Fecal Matters
Has Open Services Peaceful and Orderly Has Active Brgy. Tanod
Name and Signature of CDT: ________________________________________________________
Date Conducted: ______________________________________
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Early Childhood Care and Development Council
16.6. Public Transportation
School Bus Jeep Bus Banca Calesa
Tricycle Pedicab Habal-Habal Others
Goes to School with
Mother Father Both Parents Siblings Relatives
Grandparents Relatives Maid None
Name of Respondent ________________________________________________________
Contact Number ___________________________________
Name and Signature of CDT ___________________________________________________________
Date Conducted _____________________________________________________________
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