Republic of the Philippines P JOCIAL WELFARE AND OEMELOS MUNICIPALITY OF = MenilaHo OF feria lua Name of Preschool Teacher : Py Waer- 1 rca MSWDOPAHINTULOT PARA SA DAY CARE SERVICE Kami/ako at (Tatay/Nangangalaga) (Nanay/Nangangalaga) na nasa wastong gulang, nakatira sa : , ay mga magulang/nangangalaga sa batang si _ Na ang nabanggit na bata ay ipinanganak noong sa Na siya ay marapat lamang makapakinabang sa Day Care Service sa pamamagitan sa pagpasok sa (Pangalan ng Day Care Center) Dahil dito ay ipinagkakaloob namin ang aming pahintulot na makapakinabang ang aming anak ng Day Care Service sa panahon/tagal na nabanggit sa itaas. Dahil dito ay ibibigay namin ang aming suporta sa iba't ibang Gawain at itutuloy namin ang mga nabanggit sa aming tahanan para maabot ang layunin ng Day Care Service para sa kapakanan na aming anak. Dahil ditto ay iuulat naming ang mga problema sa Day Care Worker/Social Worker at makikiisa kami sa ikalulutas nito. Ang pahintulot na ito ay naipaliwanag sa amin at ito ay aming naunawaan. Ipinagkaloob ngayon sa Lagda ng Tatay/Nangangalaga Lagda ng Nanay/Nangangalaga Social Worker Day Care Worker MSWDOPROMISSORY NOTE TO SUBMIT We the parents/guardian of who is currently enrolled at Day Care Center have agreed to submit his/her Birth Certificate and Health Record on or before the evaluation Date Started on the ECCD Checklist (Early Childhood Care and Development) as one of the requirement upon admission to Day Care Service conducted by Municipal Social Welfare and Development Office, (address) Parent/Guardian DCW DateSOCIODEMOGRAPHIC PROFILE 1 PERSONAL DATA Child's Name: Sex: Religion: le: Date of Birth: Placerot Birt: ov te Address: Height: Weight / NS: Physical Disability, if any (specify): Health Record: Allergies Chronic Condition: Child's Handedness [ ] Right [ ] Left [ ] both [ ] not yet establish Father's Name: I. FAMILY COMPOSITION Name AIS] a. Time Attitude Civil |Relation | Educ’l Health By Birth Order | G | E ‘ a ni tien} Income Toward (indude chia) | E | x | Setied eich ier oecor } Condition cri TemCSOTY Mi. DEVELOPMENT INFORMATION Birth Certificate: available not available Marriage Contract: Date of Marriage Registry No. Child Development checklist ena Check if Child's achievement on admission for day care service corresponds to 50% and above, of indicator for his age, using the child development checklist. a. gross motor domain f. expressive language domain b. fine motor domain g. cognitive domain c. self-help domain h. social emotional domain d. receptive language domainIV. Home Condition . 1. Home conditions that are observed are likely detrimental to the child (e.g. Mother working part of the day but leaves no adequate adult supervision to child.) 2. Condition in the neighborhood those are detrimental to the child (e.g. presence of gambling places, near streets, etc.) 3. Distance of Home Day Care Center Transportation facility to day care center 4. Name of escort for child 5, Adult who will receive child on return from day care center VI. Parent Expectation 1. What do parents expect to learn from attendance at the day care? 2. What are the parents perceived in calculating values to the child at home? 3. What are the parent's foles to maintain good relationship with the Day Care Worker? i 4. What they expect of the social worker? 5. What is the parent's Peed roles | in contributing to the success of the DC Service Prograrh? Ss es a 6. What do parents expect of their children at the day care center? 7. Other Expectation Vil. Evaluation and Recommendation 1. Assessment of eligibility of the child for day care service: 2, Recommended period of day care service (time and months of day care service), Accomplished by: Day Care Worker Reviewed by: Monitoring Staff DateEARLY CHILDHOOD CARE AND DEVELOPMENT (ECCD) Checklist 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 is administered. Each month is composed of 30 days. Do not round off the months of years. | Year | Month Day | Examiner's Name Date Tested Child's Date of Birth Child's Age Date Tested PRAM Child's Date of Binh Child's Age Date Tested Child's Date of Birth Child's Age a Peo lg RIC) SugGROSS MOTOR DOMAIN Climbs on chair and other elevated piece of furniture like a bed without help. 1 | Nakakaakyat sa bangko o iba pang mataas na kasangkapan sa bahay tulad ng kama ng hindi tinutulungan. 1" Eval “Eval. | Walks backward. 2. | Nakakalakad ng patalikod 0 paurong. Runs without tripping or falling, 3 | Nakakatakbo ng hindi natutumba o natatalisod. | Walks downstairs, 2 feet on each step, with one hand held. 4 | Nakakababa ng hagdanan 2 paa Sa baitang, na nakahawak sa hawakan o baybay ng hagdan. Walks upstairs holding onto a handrail, 2 feet each step. Nakakaakyat sa hagdanan na nakahawak sa hawakan o baybay ng hagdanan 2 paa sa bawat baitang. Walks upstairs with alternate feet without holding onto a handrail 6 Umaakyat sa hagdanan na halinhinan ang paa at hindi humahawak sa baybay ng hagdanan. Walks downstairs with alternate feet without holding onto a handrail. 7 | Nakakababa ng hagdanan ng halinhinan ang paa at hindi kumakapit sa hawakan o baybay ng hagdanan, barandilya. Moves body parts as directed. 8 | Sinusunod ang sasabihing kilos o galaw. g_ | Jumps up. Nakakalundag.GROSS MOTOR DOMAIN | Throws ball overhead with | direction. 10 | Naihahagis ang bola mula sa ibabaw ng ulo sa direksyon na ninanais. Eval, 2° Eval. stEval Hops 3 steps on preferred foot. 11 | Nakakalundag ng 3 gamit ang nakasanayang paa. 12 Jumps and Tums. Nakakalundag at nakakaikot. Dances patterns/joins group 13 movement activities. | Nakakasayaw o nakakasabay sa mga gawaing pang-grupo. Total Score (Bilang ng Iskor)FINE MOTOR DOMAIN Eval, 2" Eval. Uses all 5 fingers to get food/toys placed on flat surface. Kayang kunin/pulutin ang pagkain O laruan gamit ang limang daliri na nasa patag na lugar. Pick up object with thumb and index finger. Kayang kunin/pulutin ang pagkain © laruan gamit ang hinlalaki o hintuturong daliri. Displays a definite hand preference. Naipapakita 0 naipapamalas ang kasanayan ng kamay (kaliwa o kanan). Puts small objects in/out of containers. Inilalagay sa loob at inilalabas sa isang lalagyan ang maliit na bagay. | —L Hold crayon with all the fingers of his hands though making a fist (i.e., palmar grasp) Nakahawak ang lahat ng daliri ng kamay sa krayola parang nakatikom na kamao. Unscrew the lid of a container or unwraps food. Nabubuksan ang boteng de roskas o nababalatan ang kending nakabalot. Scribbles spontaneously. ; Kusang sumusulat 0 guri-guring sumulat. Total Score (Bilang ng Iskor)FINE MOTOR DOMAIN Scribbles vertical and horizontal lines. Nakakasulat ng pahalang o patayo na linya. 4 Eval. 2° Eval, Eval, Draw circle purposefully. Nakakaguhit ng pabilog. 10 Draw a human figure (head, eyes, trunk, arms, hands/fingers). Nakakaguhit ng tao (ulo, mata, katawan, braso, kamay/daliri) Draw a house using geometric forms. Makakaguhit ng bahay gamit ang iba’t-ibang hugis. Total Score (Bilang ng Iskor)SELF-HELP DOMAIN Feed self with finger food (e.g, biscuit bread) using finger. Gamit ang kamay/dalin, nakakakain ‘mag-isa ang bata ng finger foods tulad ng biscuit, tinapay at iba pa. Feeds self using fingers to eat rice viands with spillage. ‘Mag-isa kumakain ng kanin at ulam gamit ang dalir/kamay na may kalat na natatapon. Feeds self using spoon with spillage. Magrisa kumakain ng kanin at ulam gamit ang kutsara na may kalat 0. Natatapon. Feeds self using fingers without spillage. Nakakain ang kanin at ulam gamit ang daliri/kamay na walang kalat 0 natatapon. Feeds self using spoon feeding without spillage. ‘Kumakaing mag-isa ng kanin at ulam gamit ang kutsara na walang kalat 0 natatapon. Eats without need for spoon feeding during any meal. Nakakakain mag-isa, hindi na sinusubuan. Helps hold cup for drinking. Tinutulungan uminom sa tasa. Drinks from cup with spillage. ‘Nakakainom ng may natatapon otulo. | _ Drinks from cup unassisted. Nakakainom na sa tasa ng mag-isa. Get drink for seff unassisted. Mag-isa nakakainom at walang umaalalay. Pours from pitcher without spillage. Nakakapagbuhos ng tubig mula sa pitse! ng walang natatapon. Prepares own food/snacks. Inihahanda ang sarling pagkain. 13 Prepares meals for younger siblingsfamily members when no adult is around. Nakakapaghanda ng pagkain para sa nakakabatang kapatid o pamilya kung walang matandang kasama.SELF-HELP DOMAIN wEval, | 2 Eval. Dressing sub-domain Participates when being dressed (e.g. raises arms or lift leg). ‘Sumusunod kapag binihisan (itaas ang kamay, tas ang paa). Pulls down gartered short pants. Naghuhubad ng pantalon na de garter nang mag-isa. Removes sando. Naghuhubad ng sando mag/isa. Dresses without assistance except for buttoning and tying Nekakapagsuot ng damitnakakapagbihis mag-isa maliban sa pagbubutones o pagtatali. | Dresses without assistance including buttons and tying Mag-isang nakakapagbihis ng walang tumutulong kahit pa sa pagbubutones o pagtatali. Toilet Training sub-domain Informs the adults only after he has already urinated (peed) or moved his bowels (poohed) in his underpants. (e.g. comfort room). Naipapaalam lamang sa nakatatanda matapos niyang umihi o dumumi sa kanyang salawal. Informs the adult of need to urinate (pee) or move bowels (pooh-pooh) so he can be brought to a designated place. Nagsasabi sa nakatatanda na gusto rniyang umihi o dumumi para dalhin siya sa banyo. Goes to the designated place to urinate (pee) or move bowels (pooh) but sometimes still does this in his underpants. Kaya na niyang pumunta sa banyo kapag nakakaramdam ng pag-ihi o pagdumi kahit na minsan ay napapaihi 0 napapadumi pa rin siya sa salawal22 SELF-HELP DOMAIN Goes to the designated place to urinate (pee) or moved bowels (pooh) and never does this in his underpants anymore. Kaya na niyang pumunta sa banyo kapag nakakaramdam ng pag-ihi o pagdumi at hindi napapaihi o napapadumi sa salawal. a" Eval. 2° Eval. T geval. 23 Wipesiclean self after a bowel movement (pooh). Nagpupunas o naglilinis mag-isa pagkatapos dumumi. Bathing sub-domain 24 Participate when bathing (e.g. rubbing arms with soap). Sumasali sa pagligo sa kanya tulad ng pagsabon. 25 Washes and dries hands without any help. Naghuhugas at tinutuyo ang mga kamay 1g hindi tinutulungan. 26 Washes face without any help. Nakakapaghilamos mag-isa. 27 Bathes without any help. Nakakapaligong mag-isa at walang tulong galing sa iba. Total Score (Bilang ng Iskor)RECEPTIVE LANGUAGE DOMAIN a" Eval. Eval, | 3° Eval, Points to a family member when asked to do so. Ituturo ang ka-pamilya na babanggitin. Points to 5 body parts on himself when asked to do so. Naituturo ang limang bahagi ng kanyang katawan. Points to 5 named picture objects when asked to do so. Naituturo ang limang larawan na babanggitin ng tagapanayam. af Follow one-step instructions that include simple prepositions (e.g. in, on, under, etc.). Nakakasunod sa isa-isang “instruction” na may payak na pang-ukol (simple preposition). Follows 2 step instructions that include simple prepositions, Nakakasunod sa dala-dalawang “instruction” na gamit ang mga payak na pang-ukol (simple preposition) Total Score (Bilang ng Iskor)EXPRESSIVE LANGUAGE DOMAIN aor [ater oC ee elt eT (Ragtatass) Faas (Kakayahan sa Pandinig) Uses 5 to 20 recognizable words. 1 | Nakakapagsabi ng 5 hanggang 20 malinaw na mga salita. Uses pronoun (e.g. Ime) 2 | Gumagamit ng mga panghalip (hal. Ako, akin). Uses 2 to 3 word verb-noun combination. 3. | Nakakabuo ng 2-3 kumbinasyon ng pandiwa at pangalan ng mga larawan sa aklat. Name object in the pictures 4. | Nasasabi ang tamang pangalan ng mga | Jarawan. Speaks in grammatically correct 2 to 3 5 | words and sentences. Nakakapagsalita ng 2-3 malinaw at tamang salita at pangungusap. ‘Ask “what” question. 6 | Nagtatanong ng mga tanong na | nagsisimula sa ‘ano’. ‘Ask “who” and “why” questions. 7 | Nagtatanong ng mga tanong na nagsisimula sa “sino” at “bakit” Gives account of recent experiences (with prompting) in order of occurrence 3 | using past tense Naikukuwento ng bata ang mga bagong karanasan niya (may guide) na may pagkakasunod-sunod ang pangyayari Total Score (Bilang ng Iskor)COGNITIVE DOMAIN Looks in the direction of fallen object. Tumitingin sa direksiyon ng nahuhulog na bagay. Look for a partially hidden object. Tinitingnan ang bahagyang nakatagong bagay. Imitate behavior just seen a few minutes earlier. Ginagaya ang kilos na kakikita-kita pa lamang. Offers an object but may not release it. Inaalok ang hawak na bagay pero hindi naman binibitawan. Look for a completely hidden object. Hinahanap ang nakatagong bagay. Exhibits simple “pretend” play (feeds, put doll to sleep). ‘Nakikitang nagialaro ng kunya- kunyarian (Hal. Nagpapakain o nagpapatulog ng manika). | Matches objects. | Pinagsasama-sama ang magkakatulad | na bagay. | Matches 2 to 3 colors Kayang makapagpares-pares ng 2.0 3 kulay. Matches pictures. Kayang magpares-pares ng mga larawan. | Sorts based on shapes. Nagsasama-sama ang magkakatulad. Sorts objects based on to 2 attributes (e.g. size and color). Nakapag-aayos ng mga bagay ayon sa kanilang katangian (laki at kulay). 12 Arrange objects according to size from smallest to biggest. Nakapag-aayos ng mga bagay ayon sa laki mula sa pinakamaliit hanggang sa pinakamalaki. 13 Name 4 to 6 colors. Napapangalanan ang 4 hanggang 6 na kulay. 14 Copies shapes Nakakakopya ng mga hugis.COGNITIVE DOMAIN 1 Eval. Names 3 animals or vegetables when asked Napapangalanan ang tatlong hayop 0 gulay kung tatanungin. State what common household items are used for. Nakapagsasabi kung saan ginagamit ang mga pambahay na gamit. Can assemble simple puzzles. Nakakabuo ng payak na puzzies. 18 | Demonstrate an understanding of Opposites by completing a statement, ‘Naipapakita at naiintindinan ang mga kabaligtaran sa pamamagitan ng Pagtatapos sa pangungusap tulad ng “Ang aso ay malaki, ang daga ay 9" | Points to the left and right sides of body. | "Naituturo ang kaliwa at kanang bahagi ng katawan. 20 Can state what is silly or wrong with pictures. Masasabi/matutukoy ang mali sa larawan (e.g. Ano ang mali sa larawang ito?) 21 Matches upper case letters and matches lower case letters ‘Maipagpapares-pares ang mga malalaking titi gayundin ang mga malilit na tik. Total Score (Bilang ng Iskor)SOCIO EMOTIONAL DOMAIN Eval. | 2” Eval. Enjoy watching activities of nearby people or animals. Natutuwang panoorin ang mga ginagawa ng mga tao o hayop sa paligid. Friendly with strangers but initially may ‘show slight anxiety or shyness. Sa simula ay medyo mahiyain o may- alinlangan. Plays alone but like to be near familiar adults or brothers and sisters. Naglalarong mag-isa ngunit gustong malepit sa mga kakilalang nakakatenda | 0 sa mga kapatid, | Laughs or squeals aloud in play. Tumatawa ng malakas o humahagikgik habang naglalaro. | | Plays peek-a-boo (bulaga). Nakikipagiaro ng bulagaan. Via Rolls back interactively with tr 2h OL giver/examiner. Nakikipaglaro ng gulungan " bola sa tagapag-alaga. Faye fp Hugs or cuddles toys. Niyayakap 0 niyayapos ang mga larvan. COP} hore Demonstrates respect for elders using terms like “po” and “opo”. Nagpapakita ng paggalang sa nakakatanda tulad ng paggamit ng salitang po at opo. Shares toy with others. Nagpapahiram ng laruan sa ibang bata. 10 Imitates adult activities (e.g. cooking, washing). Gumagawa sa mga gawaing pangmatanda tulad ng pagluluto, pagialaba, etc. Identifies feelings in others. Nasasabi o natutukoy ang nararamdaman ng iba. 12 ‘Appropriately uses cultural gestures of greetings without much prompting (e.g mano, bless, kiss, etc.) Nagagawa sa tamang pagkakataon ang mga pagbati sa kulturang Pilipino tulad _ng pagmamano, paghalik sa pisngi, etc.. 13 Comforts playmates/siblings in distress. Inaalo ang kalaro/kapatid na nasaktan, natatakot o nalulungkot,SOCIO EMOTIONAL DOMAIN cls Socio Emotional Domain ss ee) (Pansarili at Panlipunang Damdamin) Persist when faced with a problem or obstacle to his wants. 14 | Matiyagang tinatapos o hinahanapan ng sagot ang problema o sagabal sa kanyang gustong mangyari. : Helps with family chores (e.g. wiping tables, 15 watering plants, etc.) Tumutulong sa gawaing bahay tulad ng Pagpupunas ng lamesa, pagdidilig, etc. J Curious about environment but knows when to stop asking question of adult. 16 | Inuusisa ang mga nakikita sa kapaligiran ngunit | alam din niya kung kailan titigil sa pagtatanong sa mga nakatatanda. e 17 Wait for his turns. Naghihintay ng kanyang oras. : Ask permission to play with toy being used by 18 another. Nagpapaalam kapag angi lena FIA eer ng” iba. 19 Defends possessions with Rertieioe Desididong ipagtanggol ang kanyang pag-aari. Plays organized group games fairly (e.g, does not 20 | cheat to win). Nakikipaglaro ng tama at hindi nandadaya. Can talk about complex feelings (e.g. anger, | 1 sadness, worry) he experiences. Nakapagkukuwento ng mga nararamdaman na | karanasan (kalungkutan, pag-aalala). Honors a simple bargain with caregiver (e.g. plays outside only after cleaning/fixing his/her room) Iginagalang/Sinusunod ang mga simpleng 22 | napagkasunduan nila ng mga tagapag-alaga tulad ng makapagialaro lamang sa labas pagkatapos linisin/ayusin ang kanyang silid laruan. Watches responsibly over younger siblings/family 23 members. Binabantayan ang mga nakababatang kapatid o miyembro ng pamilya. Corporate with adults and peers in group situations to minimize quarrels and conflicts. 24 | Nakikipagtulungan sa mga nakatatanda o kagrupo upang maiwasan o mabawasan ang hindi pagkakaunawaan 0 pag-aaway. . Total Score (Bilang ng Iskor) Cs Cert CeyName of Examiner Date administered Place where test is administered Scholl) ava sitet atl at semnie: finee sat aap: amy on} Se fe ee es EET To the examiner: 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 the help stimulate the child's development). Home Environment (ex. Facilities/ type of house/ household items/ interaction/ etc.) OthersTransfer the raw score for each domain to the table below. Using the Scaled Score Equivalent of Raw Scores Table, convert the raw score to Scaled Scores appropriate to the age of the child. To arrive at the sum of Scaled Scores, add the Scaled Scores 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 Child's Age Child's Age Gross Motor 1" Evaluation Date: 2 Evaluation Date: 3” Evaluation Date:_ Child's Age Fine Motor Seff-Help Expressive Language Cognitive Socio Emotional Receptive Language | ‘Sum of Scaled Scores Standard Scores. Interpretation yr | Interpretation of Scaléd Score |__ Scaled Score Interpretation 1-3 | months Development in the domain must be monitored after 3 4-8 | months Development in the domain must be monitored after 6 7-13 | Average overall development in the domain 14 — 16 | Suggests slightly advanced development in the domain 17 - 19 | Suggests highly advanced development in the domain interpretation of Scaled Score Scaled Score Interpretation 69 and below | Overall development must be monitored after 3 months 70 - 79 | Overall development must be monitored after 6 months 80 — 119 | Average overall development 120 — 129 | Slightly advance overall development 130 and above | Highly advance overall developmentSCALED SCORE 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. DOMAIN Pe | | PYZAM Ww Ww wo wg wo 25 4 35 25 4 2 50 Zz 50 Zz 50 ~ i 92 2 Oz 2 92 2 ra 23 Q| le 25 9 |e Z¢ Q Mee Ju 6 Se 30 5 Se Su 5 meoOoW sus Q0oW sus) lOOouwsus moe ged l25a2925) BF a2a eo u Ae QBstowsSs) |ySregea OeLwae ZS] |nzF Z4| |g =F z< mac sack Ss Su SSEGS| lout kegs Pec ziuwxo F2Zuuxod ezau%060 MEOW NKWOD OLHLWOH [OtToriida zg] Meee eee) lore eve el lev eveve 5 §|18)¢ ee eee ol leer cece leovveee Bizle wv eeee eoeesee eeeeeee @| 16 le eee seer eee 2 a(Sleees e] je eevee e gii4jeees HOQPY..... g| 13) eee eoeeeene z|12/e eee Hiliwre © ee oe Elitle eee eo eeeee S| 10]eevcecel levccves eee veenes 3 Cl 9 lee eeeve eee eee eo) lee eevee & S|8leeeseve Ci) ee rr Gl 7leeeeene eoeoeeee eoeoeeee £ B/G ]eeseeee ere eee e| leer eens oj 5|*eeeeee eoeeoeeven eeereeee Plaleeceevee eoeveeee eeoeoeevne 5 Bla leecveee eeeeoeee eeeeeee Slole ec ecee eeeeeee eeeoeeee c tjeeeereee eoeeeveee eoereeeveSTANDARD SCORE . Mark an x on the corresponding Scaled Score for test administration and connect the x's. Write the date for each test administration. AGES Syears&1Month | dyears | Suggested Advance Development Average Development Re-test after 3 to 6 monthsStandard Score Equivalent of Sum of Scaled Scores Table Child's Record 2 SUM OF SCALED ‘STANDARD ‘SUM OF SCALED ‘STANDARD SCORE SCORE SCORE SCORE 29 37 64 88 30 38 65 89 34 40 66 91 32 4 67 92 33 43 68 94 34 44 69 95 35 45 70 97 36 47 1 98 37 48 72 100 38 50 73 101 39 51 74 103 40 53 75 104 4 54 76 105 42 56 7 106 43 87 78 107 44 59 79 110 45 60 80 11 46 62 81 113 47 63 82 114 48 65 83 116 49 66 84 117 50 67 85 119 51 69 86 120 52 70 87 422 53 72 88 123 54 73 89 124 55 75 90 126 56 76 91 127 57 78 92 129 58 79 93 130 59 81 94 132 60 82 95 133 61 84 96 135 62 85 7 136 63 86 98 138Scaled Score Equivalent of Raw Scores Table Child’s Record 2 Ages 3.1 - 4.0 years San GROSS | FINE a RECEPTIVE | EXPRESSIVE | COGNITIVE EMOTIONAL 1 08 5 09 7 oe : ot 1 x = 0 = - : 0-11 3 5 = 14 o-4 3 7 2 4 3 4 12 = 4 tl is 5 6 5 73-14 2 - 23 14 6 7 . 15 z 5 : 1 7 8 6 16 3 § i z s & 3 é 6 17-16 3 . 7 78-19 = a a 8 10 10 8 20 4 i, a # 4 1 z 24 = 5 io a 12 12 8 2 5 8 i 2 13 : ~ | 23-24 - E 12 a ff = & os 5 : B14 24 15 5 1 26 - = # : 16 : 5 27 Z - is = 7 : s E - : ¢ ; 18 F : 2 z - is ‘i 8 : = = =| 79-24 : Ages 4.1 - 5.0 years + tani SELF- SOCIO Score | GROSS | FINE | fer | RECEPTIVE | EXPRESSIVE | COGNITVE | eyerriny 1 05 03 0-15 o E o 0-43 2 6 4 16 £ ss | a z : = 7 > T = 23 15. a 7 5 Tn | = 4 6. 4 3 i ce ea 5 7 s e 8 a 3 : 67, - 8 : = zl 2 : 3 16 i a “ 2H 7 7 9-10 19 5 , 3 2 4 5 i 20 10 a 9 D z a a a 11 2 5 24 5 8 ee 12 - 10 2 = : or ie = “ 36 ; : 16-17 24 14 - i1 Zi, “ 7 : a : u " = ‘i 79-20 5 16 r Z = 2 = a : 17 : Z ‘ S E ; 18 5 5 : : ; . 19 zi : Ee + ss -SCHOOL HEALTH CARD DENTITION STATUS AND TREATMENT NEEDS sams | | [| | [TTT RIGHT [55 [5a [56 [52 [51 [61 | 7] = aaa ae [or [oe [os [oe [f(a | [a] PPP) PP-P-IK Zip he 2 Place of Delivery Hospital Home Others (please specify) 9 State complication if any: 9 Allergies, if any: Immunization Dates Given Ast 2nd 3rd Newborn screening OPT POLIO BCG MEASLES TETANUS HEPATITIS B Others (please specify) Deworming Date of Last Deworming Yes No Disability/impairment: Please check in any: Congenital deformities Speech Defect Deafness Emotional disturbances Others (please specify)Growth Chart Record information along the Month-weighing line using the symbols below: HEIGHT (cm) AGE (years) o 6 2 Bw me AGE (months)OBSERVATION RECORD Observation Loy EYe dC)DAY CARE CENTER HOME VISIT REPORT Name of Child: Address: Date of Home Visit: Reason ofHome Visi: Action Taken: Follow-up: ‘Signature of Parent DCW HOME VISIT REPORT Name of Child: Address: Date of Home Visit: Reason of Home Visit: Action Taken: Follow-up: ‘Signature of Parent DewDAY CARE CENTER INDIVIDUAL PARENT’S CONFERENCES Highlight Terese re aU ctNARRATIVE REPORT (Consolidation and synthesis children’s assessment after an 8-months period from time of entry.)Children’s Att Yorks Samples+ Printed By: Af JERICOPIM PUBLISHING HOUSE Purok 6. Brgy. Sapang, Jaen, Nueva Ecija Ler To an Wu) toe ULC D Role) YUM UCM ee eee) Email Address: jericopim@yahoo.com Sage eES, v,