1st Evaluation 2nd Evaluation 3rd Evaluation

Date: Age: Date: Age: Date: Age:

DOMAIN
Raw Scaled Raw Scaled Raw Scaled
Score Score Score Score Score Score

Gross Motor

Fine Motor

Self-Help

Receptive
Language

Expressive
Language

Cognitive

Social
Emotional

Sum of Scaled
Score

Standard Score

Interpretation

SCALE
 D INTERPRETATION
SCORE
1-3 Development in the domain must be monitored
after 3 months.
4-6 Development in the domain must be monitored
after 6 months.
7-13 Average over-all development in the domain.

14-16 Suggests slight, advanced development in the

domain.
17-19 Suggests highly, advanced development in the
domain.

STANDAR
D INTERPRETATION
SCORE
69 and Over-all development must be monitored
below after 3 months.
70-79 Over-all development must be monitored
after 6 months.
80-119 Average over-all development.

120-129 Slight, advanced over-all development.

130 and Highly, advanced over-all development.

above
Dear Parents, Republic of the Philippines
Province of Pangasinan
This ECCD Card show the ability and progress of your child based Municipality of Mangatarem
on Seven (7) Development Domain. There is no pass or fail score. This is MUNICIPAL SOCIAL WELFARE AND DEVELOPMENT OFFICE
only summary of ECCD Checklist. Any results we will give suggestions on
what else you can do to stimulate your child’s development.

EARLY CHILDHOOD CARE AND

DEVELOPMENT CHECKLIST
PARENT/GUARDIAN’S SIGNATURE

FIRST EVALUATION:___________________________________________

SECOND EVALUATION:_________________________________________ Child Development Center

THIRD EVALUATION:__________________________________________

Child’s Name

________________________ ______________________
ECCD Service Provider DAYCARE WORKER 1 Date of Birth(m/d/y) Age Sex

Parent/Guardian’s Name

NELFA Q. EVANGELISTA,RSW
MSWDO

ECCD Service Provider

Punong Barangay