Professional Documents
Culture Documents
___________________________________________________________________
(Name of School)
Each item observed are recorded three times within a year: 1) at the start of the year, 2) at the middle of the year and 3)
at the end of the year.
Columns:
P – Present or the child can do the task
O – Observe or the child was observed doing the task
R – Report given by the parents/caregiver about the skill
Please fill out the spaces below for the additional information.
Score: Thank you very much. Write down your notes, descriptions and
( √ ) Present or child is able to do the task
( - ) Skills is not present or child does not respond observations on the following points.
( -9) no opportunity to observe the skill
Others:
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21
COGNITIVE DOMAIN P O R COMMENTS P O R COMMENTS P O R COMMENTS The front page of the Checklist includes the portion of the socio-demographic information of the
6. Exhibits simple pretend child that must be filled out completely. Compute the child's age by subtracting the date he was born form
play (feed, put doll to the test that was administered.
sleep)
7. Matches objects
For example: Date of Exam: 2001 – 03 – 12
22
examiner must try to elicit the skill. The examiner may ask the parent/ caregiver if a skill is present or A. 3.1 – 5.0 Years
absent only when she is in doubt about the child's ability to display the skill, like if the child is not willing to EXPRESSIVE LANGUAGE P O R COMMENTS P O R COMMENTS P O R COMMENTS
respond/ perform because he is shy or not in the mood. If the child tries to do what is being asked but does DOMAIN
not succeed, it is scored as “not present” ( -). 1. Uses 5-20 recognizable
words
Any observation or comment regarding a specific item or the response of the child may be written 2. Uses pronouns (e.g. I, me,
in the last column labelled “Comments”. Examples of such remarks include: item is not applicable; lack of ako, akin)
opportunity, response was not displayed 2 out of 3 trials, etc. 3. Uses 2-3 words verb-noun
combinations (hingi gatas)
WHERE TO START AND WHERE TO STOP 4. Names objects in pictures
Administer all the items.
B. 5.1 – 5.11 Years
EXPRESSIVE LANGUAGE P O R COMMENTS P O R COMMENTS P O R COMMENTS
Teaching and giving feedback DOMAIN
The examiner must be careful not to teach the item or allow the parent caregiver to prompt the child. 5. Speaks in grammatically
Also be careful not to make comments like “correct”' “very good”, “wrong”' etc. or show via facial expression correct 2-3 word
or gestures that a child is doing well or not very well. However, you can praise the child for his efforts by sentences
saying things like “good job” even if he does not succeed in the item. This will help him maintain his 6. Asks “what” questions
interest in the different activities you are asking them to do. 7. Asks “who” and “why”
questions
Eliciting Behaviour 8. Gives account of recent
Sometimes the child can actually do an activity but just needs a little coaxing. In such instances, experiences (with
gently encourage the child to give the task and remind him that he is not expected to succeed all the time. prompting) in order of
occurrence using past
Make sure you avoid the following: tense.
-Making remarks that will embarrass or humiliate the child like, “You are so big already and you still
do not know how to do that?”
COGNITIVE DOMAIN
-Comparing him to his friends or other children in the group.
-Threatening him if he does not comply like saying, “I will tell your mommy that you do not want to A. 3.1 – 4.0 Years
COGNITIVE DOMAIN P O R COMMENTS P O R COMMENTS P O R COMMENTS
do what I am asking you.”
1. Looks at direction of
fallen object
Deferring the evaluation 2. Looks for partially object
The evaluation may be deferred for another day for the following reasons: (1) The child is sick and
hidden
not feeling well. (2)The child is crying and not disposed to cooperate. 3. Imitates behavior just
seen a few minutes earlier
If the evaluation has been deferred, disregard the results of the sessions where you could not 4. Offers object but will not
complete administration of the Checklist. Consider only that which you obtained when the child was most release it
responsive. If, after 3 sessions/ attempts, you are still not able to get the child to work with you, bring the 5. Looks for completely
matter up to the supervisor. hidden object
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SELF HELP DOMAIN P O R COMMENTS P O R COMMENTS P O R COMMENTS
22 Goes to the designated
place to urinate (pee) or Age
move bowels (pooh) and 1st Evaluation Date:_______ 2nd Evaluation Date:_______ 3rd Evaluation Date:_______
never does this is his
underpants anymore
Domain ________________________
Child’s Age
________________________
Child’s Age
________________________
Child’s Age
23. Wipes/Cleans self afer a Raw Score Scaled Score Raw Score Scaled Score Raw Score Scaled Score
bowel movement (pooh) Gross Motor
24. Participates when bathing Fine Motor
(e.g. rubbing arms with
Self-Help
soap)
25. Washes and dries hands Receptive Language
without any help. Expressive Language
26. Washes face without any Cognitive
help Social-Emotional
27. Bathes without any help Sum of Scaled
TOTAL SCORE Scores
Standard Score
RECEPTIVE LANGUAGE DOMAIN Interpretation
c. Plot out the scores on the graph as well. Make sure you see the columns designated for the
child’s age.
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19 - - - - - - -
“Edukasyong Tapat at Sapat, Dapat Para sa Lahat”
“EdukasyongScaled Tapat Scoreat Sapat,
Equivalent Dapat
of Raw Para
Scores Table sa Record
Child's Lahat”2
Ages 3.1 – 4.0 7 years SELF HELP DOMAIN P O R COMMENTS P O R COMMENTS P O R COMMENTS
Scaled Gross Motor Fine Motor Self-Help 8Receptve Language Expressive Language Cognitve Social Emotonal Dressing Sub-Domain
Score raw score raw score raw score raw score raw score raw score raw score
14. Participates when being
1 0-3 - 0-9 - 0-2 - 0-9 dressed (e.g. raises arms
2 4 0-3 10 - - - 10-11
or lifs leg)
15. Pulls down gartered short
3 5 - 11 0-1 3 0 12
pants
4 - 4 12 - 4 1 13
16. Removes sando
5 6 5 13-14 2 - 2-3 14 17. Dresses without
6 7 - 15 - 5 4 15 assistance except for
7 8 6 16 3 5 16 buttons and tying
8 9 - 17 - - 6 17-18 18. Dresses without
9 - 7 18-19 - 6 7 19
assistance including
buttons and tying
10 10 8 20 4 - 8-9 20
Toilet Training Sub-Domain
11 11 - 21 - 7 10 21
19. Informs the adult only
12 12 9 22 5 - 11 22 afer he has already
13 - - 23-24 - 8 12 23 urinated (peed) o moved
14 13 10 25 - - 13-14 24 his bowels (poohed) in his
15 - 11 26 - - 15 - underpants
16 - - 27 - - 16 -
20. Informs adult of need to
urinate (pee) or moved
17 - - - - - 17 -
bowels (pooh-pooh) so he
18 - - - - - 18 - can be brought to a
19 - - - - - 19-21 - designated place (e.g.
Ages 4.1 – 5.0 years comfort rooms)
Scaled Gross Motor Fine Motor raw Self-Help Receptve Expressive Cognitve Social Emotonal 21. Goes to the designated
Score raw score score raw score Language Language raw score raw score
place to urinate (pee) or
raw score raw score
1 0-5 0-3 0-15 0-1 - 0 0-13 move bowels (pooh) and
2 6 4 16 - 0-5 1 14 never does this is his
3 - - 17 2 - 2-3 15
underpants anymore
4 7 5 18 - - 4 16
5 8 6 19 - 6 5 17
6 - - 20 3 - 6-7 -
7 9 7 - - - 8 18
8 10 - 21 - 7 9-10 19
9 - 8 22 4 - 11 20
10 11 9 23 - - 12 21
11 12 - 24 5 8 13-14 22
12 - 10 25 - - 15 23
13 13 - 26 - - 16-17 24
14 - 11 27 - - 18 -
15 - - - - - 19-20 -
16 - - - - - 21 -
17 - - - - - - -
18 - - - - - - -
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SELF HELP DOMAIN
A. 3.1 – 4.0 Years Ages 5.1-5.11
SELF HELP DOMAIN P O R COMMENTS P O R COMMENTS P O R COMMENTS Scaled Gross Fine Motor raw score Self-Help raw score Receptve Language raw Expressive Language raw Cognitve raw score Social Emotonal raw
1. Feeds self with finger food Score Motor raw score score score score
(e.g. biscuits, breads)
using fingers 1 0-10 0-5 - 0-2 - 0-9 0-15
2. Feeds self using fingers 2 - - 0-19 - - 10 16
with spillage 3 - 6 20 - - 11 17
3. Feeds self using spoon
4 11 - 21 3 - 12 -
with spillage
4. Feeds self using fingers 5 - 7 - - 0-7 13 18
without spillage 6 - - 22 - - 14 19
5. Feeds self using spoon 7 12 8 23 - - 15 20
without spillage
8 - 9 - 4 - 16 -
9 - - 24 - - 17 21
B. 4.1 – 5.0 Years
10 - 10 25 - - 18 22
SELF HELP DOMAIN P O R COMMENTS P O R COMMENTS P O R COMMENTS
6 Eats without need for 11 13 - - 5 8 19 23
EXPRESSIVE LANGUAGE
EXPRESSIVE LANGUAGE
EXPRESSIVE LANGUAGE
RECEPTIVE LANGUAGE
RECEPTIVE LANGUAGE
RECEPTIVE LANGUAGE
SOCIAL EMOTIONAL
SOCIAL EMOTIONAL
SOCIAL EMOTIONAL
SCALED SCORE
SCALED SCORE
SCALED SCORE
Suggest Advance Development
GROSS MOTOR
GROSS MOTOR
FINE MOTOR
FINE MOTOR
FINE MOTOR
COGNITIVE
COGNITIVE
COGNITIVE
SELF-HELP
SELF-HELP
SELF-HELP
A. 3.1 – 4.0 Years
Fine Motor P O R COMMENTS P O R COMMENTS P O R COMMENTS
1. Uses all 5 fingers to get
food/toys placed on flat
surface.
2. Picks up objects with
thumbs and index finger
1 3. Displays a definite hand
19 19 preference
9
1 4. Puts small objects
18 18 in/out of containers
8
1 5. Holds crayon with all
17 17 fingers of his hand
7
1 making a list (i.e. palmar
16 16
grasp)
Average Development
6
1
15 15
5
B. 4.1 – 5.0 Years
1
14 14 Fine Motor P O R COMMENTS P O R COMMENTS P O R COMMENTS
4
1 6. Unscrews lid of
13 13 container or unwraps
3
1 food
12 12 7. Scribbles spontaneously
2
1 8. Scribbles vertical and
11 11 horizontal lines
1
1
10 10
0 C. 5.1 – 5.11 Years
Re-Test after 5-6 months
Scaled Standard
Interpretaton Interpretatons
Score Score
Development in the domain must 69 and Overall development must be
1–3
be monitored afer 3 months below monitored afer 3 months
Development in the domain must Overall development must be
4–6 70 - 79
be monitored afer 6 months monitored afer 6 months
Average overall development in
7 – 13 80 – 119 Average overall development
the domain
Suggests slightly advanced Slightly advanced overall
14 – 16 120 – 129
development in the domain development
Suggests highly advanced 130 and Highly advanced overall
17 – 19
development in the domain above development
Add the Scaled Score of each of the seven domains. This is called the sum of the Scaled Scores. Theoretically the
sum cannot be less than 7 or more than 133. Refer to the Tabell of Standard of Scores. Locate the Sum of Scaled
Scores that you arrived at, and then find the corresponding Standard Score for this which is printed in the column
labelled “Standard of Scores”.
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“Edukasyong Tapat at Sapat, Dapat Para sa Lahat”
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