SOCIODEMOGRAPHIC PROFILE

Intake form for Day Care Worker

I. PERSONAL DATA
Child’s Name: __________________________________________________________________
Age: ________ Sex: ______ Religion: ________ 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: _________________________________________________________________

Name of Birth Order (include child) AGE SEX Civil Relation Educ. Time present Occupation Income Health Attitude
Status to Child Attain’t at home condition toward child

II. FAMILY COMPOSITION

III. DEVELOPMENT INFORMATION

1. Birth Certificate: Available ____________________ Not Applicable: -____________________
2. Marriage Contract: Date of Marriange __________________ Registry No. ________________
3. Child Development Checklist _____________________________________________________
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 ______ b. fine motor domain _____ c. self-help domain
______ d. receptive language domain ____ e. expressive langauage domain _____ f. cognitive domain
______ h. social emotional 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 tp child.) ________________________________________________
2. Condition in the neighborhood those are detrimental to the chidld (e.g. presense 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 on return from Day Care Center ____________

IV. PARENT EXPECTATION

1. What do parents expect to learn from attendance at Day Care? __________________________________
2. What are the parents perceived in calculating values to child at home? ____________________________
3. What are parent’s roles to maintain good relationship with the day care workers? ____________________
4. What are expect of the social welfare? ______________________________________________________
5. What is the parents perceived roles to maintain good relationship with Day Care Worker? ______________
6. What do parents expect of their children at the day care center? __________________________________
7. Other expectations _______________________________

VII. Evaluation and Recommendations

1. Assessment of eligibility of the Children at the day care center? ___________________________________
2. Recommend period of day care service (time and months of day care service)
__________________________________________________________________________________

Accomplished by:
___________________
Child Development Worker
Reviewed by:
_____________________ ___________________
Monitoring Staff Date