INTAKE

Date: ___________

I. PERSONAL DATA

Name of Child: ___________________________________________Age: __________Sex: __________

Date/Place of Birth: _______________________________________Religion______________________
Address: ____________________________________________________________________________
No. Street Zone Barangay Municipality/City Province
st
1 Quarter 2nd Quarter 3rd Quarter

Height: _________ Weight/Nutritional Status:

Physical Disability, if any: _______________________________________________________________

II. FAMILY COMPOSITION

Family composition include parents and all members of the family who live as one household.
(i.e. share dwelling, same source of income and the same kitchen)

Name Time
Educational Health
-By birth Order- AGE SEX Civil Status Rel. to Child Present at Occupation Income Attitude
Attainment Condition
(Include child) Home

III. DEVELOPMENT INFORTMATION

1. Birth Certification:
 Available
 Not Available
2. Marriage Contract: Date of Marriage: ____________________ Registry Number: _______________
3. Child Development Checklist: _________________________________________________________

Check if child’s achievement on admission for day care service corresponds to 50% and above, of
indicators for his age, using the child development checklist.

 a. motor development
 b. personal-social development
 c. cognitive adaptive development
 d. language competency
 e. social values in relation to self
 f. social values in relation to family
 g. social values in relation to non-relatives
 h. social values in relation to God relation to country community.
IV. HOME CONDITIONS

1. Home conditions that are observed as likely detrimental to the child (e.g. mother working part of the
day but leaves no adequate adult supervision to child.)
________________________________________________________________________________
2. Conditions in the neighborhood those are detrimental to the child (e.g. presence of gambling places,
near streets, etc.)
________________________________________________________________________________
3. Distance of Home to 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 _______________________________

V. PARENTAL EXPECTATIONS

1. What do parents expect to learn from attendance at the day care center?
________________________________________________________________________________
________________________________________________________________________________
2. What are the parents perceive roles in inculcating values to the child at home?
________________________________________________________________________________
________________________________________________________________________________
3. What do the parents as their role in relation to the Day Care Worker?
________________________________________________________________________________
________________________________________________________________________________
4. What do they expect of the Social Worker?
________________________________________________________________________________
________________________________________________________________________________
5. What do the parents perceive as their role in contributing to the success of the DC Center?
________________________________________________________________________________
________________________________________________________________________________
6. What do the parents expect of their children at the Day Care Center?
________________________________________________________________________________
________________________________________________________________________________
7. Other expectations
________________________________________________________________________________
________________________________________________________________________________

VI. EVALUATION AND RECOMMENDATION

1. Assessment of eligibility of 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
 Parents’ Consent

We/I, ___________________________________ and ___________________________________ legal ages,

resident of Barangay __________________, Amulung, Cagayan are/is parent(s) of the minor
______________________________.

The minor was born on _______________________________ at _______________, Amulung, Cagayan.

Per C/SWD office basic requirements, minor is found eligible for Day Care Service and referred at
______________ Day Care Center by ____________________________ for a period of _______________ that
we consent to the provision of said service to the minor for the started period herein;

That we will provide support in the different activities and continue such activities at home in order to attain
the objectives of the program for his/her welfare.

That we are willing to pay the registration fee in the amount of One hundred Pesos (Php100.00) and a monthly
fee of One Hundred Pesos (Php100.00).

That we will report any difficulties/problems to the Social Worker/Day Care Worker and cooperate with them
to solve said problem/s.

That this consent was explained to us and we fully understand its implication.

Signed this ________ day of __________________ 2019 at ___________________, Amulung, Cagayan.

____________________________ ____________________________
Father/Guardian Mother/Guardian
(Signature over printed name) (Signature over printed name)

______________________________
CHILD DEVELOPMENT WORKER
 EARLY CHILDHOOD CARE & DEVELOPMENT CARD
CHILD’S NO.
Clinic: ____________________________________________________________
Barangay: _________________________________________________________
Family Number: ____________________________________________________

Child’s Name: _____________________________________________________ Sex: Male Female

Mother’s Name: __________________________________________________________________________

Educational Level: _________________________________________________________________________
Occupation: __________________________________________ Monthly Income: ___________________

Father’s Name: ___________________________________________________________________________

Educational Level: _________________________________________________________________________
Occupation: __________________________________________ Monthly Income: ___________________

Date first seen Birthdate Birth Weight

_________________________ _________________________ _________________________
Place of delivery Birth registered at local civil
__________________________________________ _________________________________________

Complete address of family

________________________________________________________________________________________
No. Street Zone Barangay Municipality/City Province

BROTHER’S AND SISTER’S

NAME SEX DATE OF BIRTH

ESSENTIAL HEALTH AND NUTRITION SERVICES

Date of visits
1st 2nd 3rd 4th 5th 6th
New born screening
BCG (at birth)
DPT (6 wks, 10 wks, 14 wks old)
OPV (6 wks, 10 wks, 14 wks old)
Hepatitis (6 wks, 10 wks, 14 wks old)
Measles (9 mos.)

Vitamin A (Start at 6 mos.)

Deworming
Dental Check-Up
OBSERVATIONS & RECORDS OF THE CHILD’S BEHAVIOR
Observations Discussion/s
Date
(Special Need’s) (Activity taken)
 Child’s Record 2
Age 3 years 1 month
To 5 years

Early Child Care

and Development (ECCD)
Checklist

It is recommended that the Checklist be administered to the child once a year.

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 was
administered. Each month is composed of 30 days. Do not round off the months or years. Write the examiner’s
name each time the test is administered.
Year Month Day Examiner’s Name
st Date Tested
1 Child’s Date of Birth
Assessment Child’s Age
nd Date Tested
2 Child’s Date of Birth
Assessment Child’s Age
rd Date Tested
3 Child’s Date of Birth
Assessment Child’s Age
 ECCD CHECK LIST
GROSS MOTOR DOMAIN

Gross Motor Present Comments

st
1 Eval. 2nd Eval. rd
3 Eval.
1 Climbs on chair or other elevated piece of
furniture like a bed without help
2 Walks backwards
3 Runs without tripping or falling
4 Walks down stairs, two feet on each step,
with one hand held
5 Walks upstairs holding onto a handrail, two
feet on each step
6 Walks upstairs with alternate feet without
holding onto a handrail
7 Walks downstairs with alternate feet without
holding onto a handrail
8 Moves body part as directed
9 Jumps up
10 Throws ball overhead with direction
11 Hops one to three steps on preferred foot
12 Jumps and turns
13 Dances patterns/joins group movement
activities
TOTAL SCORE

FINE MOTOR DOMAIN

Fine Motor Present Comments

1st Eval. 2nd Eval. 3rd Eval.
1 Uses all five fingers to get food/toys placed
on a flat surface
2 Picks up objects with thumb and index finger
3 Displays a definite hand preference
4 Puts small objects in/out of containers
5 Holds crayon with all the fingers of his hand
making a fist (i.e., palmar grasp)
6 Unscrews the lid of a container or unwraps
food
7 Scribbles spontaneously
8 Scribbles vertical and horizontal lines
9 Draws circle purposefully
10 Draws a human figure (head, eyes, trunk,
arms, hands/fingers)
11 Draws a house using geometric forms
TOTAL SCORE
SELF-HELP DOMAIN

Self Help Present Comments

Feeding sub-domain 1st Eval. 2nd Eval. 3rd Eval.
1 Feeds self with finger food (e.g. biscuits,
bread) using fingers
2 Feeds self-using fingers to eat rice/viands
with spillage
3 Feeds self-using spoon with spillage
4 Feeds self-using fingers without spillage
5 Feeds self-using spoon without spillage
6 Eats without need for spoon-feeding during
any meal
7 Helps hold cup for drinking
8 Drinks from cup with spillage
9 Drinks from cup unassisted
10 Gets drink for self-unassisted
11 Pours from pitcher without spillage
12 Prepares own food/snack
13 Prepares meals for younger siblings/family
members when no adult is around
Dressing sub-domain
14 Participates when being dressed (e.g., raises
arms or lifts leg)
15 Pulls down gartered pants
16 Removes sando
17 Dresses without assistance except for buttons
and tying
18 Dresses without assistance including buttons
and tying
Toilet Training sub-domain
19 Informs the adult only after he has already
urinated (peed) or moved his bowels
(poohed) in his underpants
20 Informs the adult of need to urinate (pee) or
move bowels (pooh-pooh) so he can be
brought to a designated place (e.g., comfort
room)
21 Goes to the designated place to urinate (pee)
or move bowels (pooh) but sometimes still
does this in his underpants
22 Goes to the designated place to urinate (pee)
or move bowels (pooh) and never does this in
his underpants/wear anymore
23 Wipes/cleans self after a bowel movement
(pooh)
Bathing sub-domain
24 Participates when bathing (e.g., rubbing arms
with soap)
25 Washes and dries hands without any help
26 Washes face without any help
27 Bathes without any help
TOTAL SCORE
RECEPTIVE LANGUAGE DOMAIN

Receptive Language Present Comments

1st Eval. 2nd Eval. 3rd Eval.
1 Points to a family member when asked to do
so
2 Points to five body parts on himself when
asked to do so
3 Points to five named pictured objects when
asked to do so
4 Follows one-step instructions that include
simple prepositions (e.g., in, on, under, etc.)
5 Follows two-step instructions that include
simple prepositions
TOTAL SCORE

EXPRESSIVE LANGUAGE DOMAIN

Expressive Language Present Comments

st
1 Eval. 2nd Eval. rd
3 Eval.
1 Uses five to 20 recognizable words
2 Uses pronouns (e.g. I, me, ako, akin)
3 Uses two- to three-word verb-noun
combinations (e.g., hingi gatas)
4 Names objects in pictures
5 Speaks in grammatically correct two- to
three-word sentences
6 Asks “what” questions
7 Asks “who” and “why“ questions
8 Gives account of recent experiences (with
prompting) in order of occurrence using past
tense
TOTAL SCORE
COGNITIVE DOMAIN

Cognitive Present Comments

1st Eval. 2nd Eval. 3rd Eval.
1 Looks in the direction of fallen object
2 Looks for a partially hidden object
3 Imitates behavior just seen a few minutes
earlier
4 Offers an object but will not release it
5 Looks for a completely hidden object
6 Exhibits simple “pretend” play (feeds, put doll
to sleep)
7 Matches objects
8 Matches two to three colors
9 Matches pictures
10 Sorts based on shapes
11 Sorts objects based on two attributes (e.g.,
size and color)
12 Arranges objects according to size from
smallest to biggest
13 Names four to six colors
14 Copies shapes
15 Names 3 animals or vegetables when asked
16 States what common household items are
used for
17 Can assemble simple puzzles
18 Demonstrates an understanding of opposites
by completing a statement (e.g., Ang aso ay
malaki, ang daga ay ____.”)
19 Points to left and right sides of body
20 Can state what is silly or wrong with pictures
(e.g., Ano ang mali sa larawang ito?)
21 Matches upper case letters; and matches
lower case letters
TOTAL SCORE
SOCIAL-EMOTIONAL DOMAIN

Social-Emotional Present Comments

1st Eval. 2nd Eval. 3rd Eval.
1 Enjoys watching activities of nearby people or
animals
2 Friendly with strangers but initially may show
slight anxiety or shyness
3 Plays alone but likes to be near familiar adults
or brothers and sisters
4 Laughs or squeals aloud in play
5 Plays peek-a-boo (bulaga)
6 Rolls ball interactively with
caregiver/examiner
7 Hugs or cuddles toys
8 Demonstrates respect for elders using terms
like “po” and “opo”
9 Shares toys with others
10 Imitates adult activities (e.g., cooking,
washing)
11 Identifies feelings in others
12 Appropriately uses cultural gestures of
greeting without much prompting (e.g.,
mano, bless, kiss, etc.)
13 Comforts playmates/siblings in distress
14 Persists when faced with a problem or
obstacle to his wants
15 Helps with family chores (e.g., wiping tables,
watering plants, etc.)
16 Curious about environment but knows when
to stop asking questions of adults
17 Waits for his turn
18 Asks permission to play with toy being used
by another
19 Defends possessions with determination
20 Plays organized group games fairly (e.g., does
not cheat to win)
21 Can talk about complex feelings (e.g., anger,
sadness, worry) he experiences
22 Honors a simple bargain with caregiver (e.g.,
plays outside only after cleaning/fixing
his/her room)
23 Watches responsibly over younger
siblings/family members
24 Cooperates with adults and peers in group
situations to minimize quarrels and conflicts
TOTAL SCORE
Transfer the raw score for each domain in the table below. Using the Scaled Score Equivalent of Raw Scores Table, convert
the raw scores to Scaled Scores appropriate to the age of the child. To arrive at the Sum of Scaled Scores, add the Scaled
Scores across 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
st nd
1 Evaluation 2 Evaluation 3rd Evaluation
Domain Date: ___________________ Date: ___________________ Date: ___________________
Child’s Age: ____________ Child’s Age: ______________ Child’s Age: ______________
Raw Score Scaled Score Raw Score Scaled Score Raw Score Scaled Score
Gross Motor
Fine Motor
Self-Help
Receptive Language
Expressive Language
Cognitive
Social-Emotional
Sum of Scaled Scores
Standard Score

Interpretation

Interpretation of Scaled Score Interpretation of Standard Score

Scaled Score Interpretation Scaled Score Interpretation

Development in the domain must be Overall development must be
1-3 69 and below
monitored after 3 months monitored after 3 months
Development in the domain must be Overall development must be
4-6 70-79
monitored after 6 months monitored after 6 months
Average overall development in the 80-119 Average overall development
7-13
domain Slightly advance overall
120-129
Suggests slightly advanced development
14-16
development in the domain 130 and
Highly advance overall development
Suggests highly advanced above
17-19
development in the domain
 Scaled Scores
Mark an x on the dot corresponding to the Scaled for each domain and connect the x’s.
Write the child’s age on each evaluation.
Child’s Age: ____________________ Child’s Age: ____________________ Child’s Age: ____________________
Domain Domain Domain

Expressive Language
Expressive Language

Expressive Language

Receptive Language
Receptive Language

Receptive Language

Social-Emotional
Social-Emotional

Social-Emotional

Gross Motor
Gross Motor

Gross Motor

Scaled Score
Scaled Score

Scaled Score

Cognitive
Cognitive

Cognitive

Self-Help
Self-Help

Self-Help
19 ● ●
● ● ● ● ● ● ● 19 ● ● ● ● ●
● ● ● 19 ●

Suggests Advance
Suggests Advance

Suggests Advance
18 ● ●
● ● ● ● ● ● ● 18 ● ● ● ● ●
● ● ● 18 ●
17 ● ●
● ● ● ● ● ● ● 17 ● ● ● ● ●
● ● ● 17 ●
16 ● ●
● ● ● ● ● ● ● 16 ● ● ● ● ●
● ● ● 16 ●
15 ● ●
● ● ● ● ● ● ● 15 ● ● ● ● ●
● ● ● 15 ●
14 ● ●
● ● ● ● ● ● ● 14 ● ● ● ● ●
● ● ● 14 ●
13 ● ●
● ● ● ● ● ● ● 13 ● ● ● ● ●
● ● ● 13 ●

Average Development
Average Development

Average Development

12 ● ●
● ● ● ● ● ● ● 12 ● ● ● ● ●
● ● ● 12 ●
11 ● ●
● ● ● ● ● ● ● 11 ● ● ● ● ●
● ● ● 11 ●
10 ● ●
● ● ● ● ● ● ● 10 ● ● ● ● ●
● ● ● 10 ●
9 ● ●
● ● ● ● ● ● ● 9 ● ● ● ● ●
● ● ● 9 ●
8 ● ●
● ● ● ● ● ● ● 8 ● ● ● ● ●
● ● ● 8 ●
7 ● ●
● ● ● ● ● ● ● 7 ● ● ● ● ●
● ● ● 7 ●
6 ● ●
● ● ● ● ● ● ● 6 ● ● ● ● ●
● ● ● 6 ●

Re-test after 3-6

Re-test after 3-6

Re-test after 3-6

5 ● ●
● ● ● ● ● ● ● 5 ● ● ● ● ●
● ● ● 5 ●

months
months

months

4 ● ●
● ● ● ● ● ● ● 4 ● ● ● ● ●
● ● ● 4 ●
3 ● ●
● ● ● ● ● ● ● 3 ● ● ● ● ●
● ● ● 3 ●
2 ● ●
● ● ● ● ● ● ● 2 ● ● ● ● ●
● ● ● 2 ●
1 ● ●
● ● ● ● ● ● ● 1 ● ● ● ● ●
● ● ● 1 ●
Standard Score
Mark an x on the corresponding Standard Score for each test administration and connect the x’s. Write the date for each
test administration.
AGES
3 years & 1 month 4 years 5 years
160____________ _______________ _______________ _______________
____________ _______________ _______________ _______________
150 ____________ _______________ _______________ _______________
Suggests
Advance

____________ _______________ _______________ _______________

140 ____________ _______________ _______________ _______________
____________ _______________ _______________ _______________
130 ____________ _______________ _______________ _______________
____________ _______________ _______________ _______________
120 ____________ _______________ _______________ _______________
Average Development

____________ _______________ _______________ _______________

110____________ _______________ _______________ _______________
____________ _______________ _______________ _______________
100 ____________ _______________ _______________ _______________
____________ _______________ _______________ _______________
90 ____________ _______________ _______________ _______________
____________ _______________ _______________ _______________
80 ____________ _______________ _______________ _______________
____________ _______________ _______________ _______________
70 ____________ _______________ _______________ _______________
Re-test after 3-6 months

____________ _______________ _______________ _______________

60 ____________ _______________ _______________ _______________
____________ _______________ _______________ _______________
50 ____________ _______________ _______________ _______________
____________ _______________ _______________ _______________
40 ____________ _______________ _______________ _______________
____________ _______________ _______________ _______________
30____________ _______________ _______________ _______________
____________ _______________ _______________ _______________
20
____________ _______________ _______________

Date Tested

Write down your notes, description and observations on the columns provided.
Name of Examiner:
______________________________
Date administered:
______________________________
Place of test:
______________________________
Child’s Background (ex. Behavior/health/etc.)
Family environment (ex. Health of family
members/family
problem/economic/conditions/etc.)
Parents stimulating activities for the child
(What are the activities/things that the
parents do to help stimulate the child’s
development)
Home environment (ex. Facilities/type of
house/household items/interaction/etc.)
Others
Examiner’s Notes
Name of Examiner:
______________________________
Date administered:
______________________________
Place of test:
______________________________
Child’s Background (ex. Behavior/health/etc.)
Family environment (ex. Health of family
members/family
problem/economic/conditions/etc.)
Parents stimulating activities for the child
(What are the activities/things that the
parents do to help stimulate the child’s
development)
Home environment (ex. Facilities/type of
house/household items/interaction/etc.)
Others
Name of Examiner:
______________________________
Date administered:
______________________________
Place of test:
______________________________
Child’s Background (ex. Behavior/health/etc.)
Family environment (ex. Health of family
members/family
problem/economic/conditions/etc.)
Parents stimulating activities for the child
(What are the activities/things that the
parents do to help stimulate the child’s
development)
Home environment (ex. Facilities/type of
house/household items/interaction/etc.)
Others