CHECKLIST

I - CHILD’S PROFILE
Name : _____________________________
Nick name : _____________________________
Date of birth : _____________________________
Age : _____________________________
Gender : _____________________________
Parent’s Name: _____________________________
Date of Assessment: _____________________________

II- REASONS FOR ASSESSMENT

This is conducted to find out the present level of performance to be used as a
basis for IEP development.

A. A Scale for Detecting Academic Deficits among Children

Directions: You will be asked to evaluate your child objectively based on your observation
and interactions with him/her. The child will be rated each item by checking under
the column that best describes home/her.

Legend:
HC = Highly characteristics of the child
CC = Characteristic of the child
SC = Slightly characteristic of the child
NC = Not characteristic of the child at all

The Child: HC CC SC NC

A. Writing/Language

1. Copy upper case letter A-Z independently [ ] [ ] [ ] [ ]

2. Copy lower case letter a-z independently [ ] [ ] [ ] [ ]
3. Copy two- letter- word independently. [ ] [ ] [ ] [ ]
4. Copy three-letter word independently. [ ] [ ] [ ] [ ]
5. Copy phrases independently. [ ] [ ] [ ] [ ]
6. Copy one or two sentences independently. [ ] [ ] [ ] [ ]
7. Copy a short paragraph independently. [ ] [ ] [ ] [ ]

B. Reading

1. Identify the letter sounds A-Z independently. [ ] [ ] [ ] [ ]

2. Identify the letter sounds a-z independently. [ ] [ ] [ ] [ ]
3. Associate words with pictures independently. [ ] [ ] [ ] [ ]
4. Read simple words with consonant-vowel- [ ] [ ] [ ] [ ]
consonant (CVC) pattern through pictures.

C. Mathematics

1. Identify colors [ ] [ ] [ ] [ ]
2. Identify Shapes [ ] [ ] [ ] [ ]
3. Recognizes numbers 1-100 [ ] [ ] [ ] [ ]
4. Add two 2-digit numbers with sums up to 10 [ ] [ ] [ ] [ ]
5. Subtract two 2-digit numbers with minuends up to 10 [ ] [ ] [ ] [ ]

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 6. Multiply two 2-digit numbers with product up to 50 [ ] [ ] [ ] [ ]
7. Divided two 2-digit numbers with quotient up to 20 [ ] [ ] [ ] [ ]

B. DEVELOPMENTAL SKILLS EVALUATION

Observation Remarks
SELF HELP SKILLS
Feeding
Drinks from a cup/glass
Uses eating utensils spoon, knife, fork properly
Serves self from serving plate
Cleans and clears place on table
Knows proper table setting
Dressing
Know how to dress/undress
Ties Shoes
Takes off dress, skirt, blouse
Knows how to zip/unzip
Knows how to button/unbutton
Toileting
Sounds off when wet or soiled
Uses toilet with help
Follows complete toileting, wiping, flushing,
washing hand
Hygiene and grooming
Washes hands with soap
Washes face with soap
Combs/brushes hair properly
Brushes teeth regularly
Safety
Handles sharp objects with care
Recognizes safety rules

MOTOR SKILLS Observation Remarks

Gross Motor Development
Jumps over an object with both feet
Walks forward independently
Climbs upstairs and goes downstairs using alternate feet
Fine Motor Development
Strings beads on the thread or shoelace
Cuts straight, curved, jagged, lines
Ties shoes
Puts small objects in a bottle

SOCIAL AND EMOTIONAL DEVELOPMENT Observation Remarks

Relates well with others in work Fairly Observe
Plays at ease with others Present
Exhibits self-confidence Present
Initiates interaction (through eye contact, touching, Present
and calling)
Responds to His/her name when called Present
Initiates plays with peers Present
Interacts with peers Present