COMPETENCY DOMAIN RATING SUMMARY TABLE

On the basis of the review of this infant’s/young child’s developmental capacities, complete the table below to indicate the category that
best describes the infant’s/young child’s functioning in each of the domains that comprise Axis V:
To be completed for all infants/young children. Indicate competency domain rating scores by placing an “X” in the box for the appropriate score for each develop-
mental domain.

Competency Emotional Social- Language- Cognitive Movement and

Domain Rating Relational Social Physical
Communication
Exceeds
developmental
expectations

Functions at
age-appropriate
level

Competencies are
inconsistently pres-
ent or emerging

Not meeting
developmental
expectations
(delay or deviance)

Overall impression. Provide Axis V formulation as an overall impression on the basis of the ratings above. Indicate any unevenness
of developmental competencies highlighting relative strengths and concerns. Also note whether there have been any recent changes in
competencies in any developmental domain.

Copyright © 2016 ZERO TO THREE. All rights reserved.