Guidebook in Managing Children with Delays and Disabilities / ECCD Council
OBSERVATION FORM
Name of Child: ________________________________________________________________________
Observer’s Name and Relation to Child: ____________________________________________________
Date, Time and Location of Observation Observation
Guidebook in Managing Children with Delays and Disabilities / ECCD Council
CHILD INTAKE FORM
Part A. Basic information about the child and family
A.1. Information about the child
Name: Sex:
Birthdate: Age:
Address:
A.2. Information about the parents
Father’s Name: Mother’s Name:
Age: Age:
Occupation: Occupation:
Contact number: Contact number:
A.3. Information about other members of the family/household
Name: Age: Sex: Relation to child
Part B. Medical Information of the child
Name of Specialist:
Designation:
Medical Findings:
Medical notes and recommendations:
General considerations:
Accomplished by: Date:
______________________________ ____________________
(Signature over printed name) (Month/Day/Year)
Guidebook in Managing Children with Delays and Disabilities / ECCD Council
Part C. Latest results of assessment using the ECCD Checklist
Date of assessment: Age of the child during assessment:
Domain Raw Score Scaled Score Interpretation
Gross Motor
Fine Motor
Self-Help
Receptive Language
Expressive Language
Cognitive
Socio-Emotional
Sum of Scaled Scores
Standard Score
Part D. Interview notes with the parents and/or other members of the family/household
Child’s interests: What are the things/activities does your child like or hate? Where do you think your child is very
good at doing?
Child’s behavior: How does your child behave when playing, interactin and doin family activities at home? How
does your child behave when in other places?
Child’s routine: What are the usual activities your child do with your family in a day? What does your child do from
morning until night?
Other considerations: Are there other things that you like to share about your child?
Accomplished by: Date:
______________________________ ____________________
(Signature over printed name) (Month/Day/Year)
Guidebook in Managing Children with Delays and Disabilities / ECCD Council
Individual Learning and Development Plan
Child’s Name: Sex:
Birthdate: Age:
ILDP inclusive dates of implementation:
Goal:
Objectives:
Domain: Gross Motor
Target Skills Intervention Activities
1.
2.
3.
4.
5.
Domain: Fine Motor
Target Skills Intervention Activities
1.
2.
3.
4.
5.
Domain: Self-Help
Target Skills Intervention Activities
1.
2.
3.
4.
5.
Domain: Receptive Language
Target Skills Intervention Activities
1.
2.
3.
4.
5.
Domain: Expressive Language
Target Skills Intervention Activities
1.
2.
3.
4.
5.
Domain: Cognitive
Target Skills Intervention Activities
1.
2.
3.
4.
5.
Domain: Socio-Emotional
Target Skills Intervention Activities
1.
2.
3.
4.
5.
Accomplished by: Date:
______________________________ ____________________
(Name and Designation)
Republika ng Pilipinas
Lalawigan ng Quezon
Bayan ng Catanauan
Barangay ___________
PAHINTULOT PARA SA DAY CARE SERVICE
Kami/Ako si _________________________ at ______________________ na nasa wastong
gulang, nakatira sa Brgy. Catanauan, Quezon 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 ng pagpasok
sa DEVELOPMENT CENTER.
Dahil dito ay ipinagkakaloob namin ang 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 layuninng Day Caare Service para sa kapakanan ng
aming anak.
Dahil dito ay inuulat namin ang problema sa Child Development Worker/Social Worker at
makikiisa kami sa ikalulutas nito.
Ang pahintulot na ito ay naipaliwanag sa amin at ito ay aming naunawaan.
Ipinakaloob ngayon ______________ sa Child Development Center.
__________________________ ______________________________
Lagda ng Tatay/Nangangalaga Lagda ng Nanay/Nangangalaga
