Philippine Early Childhood

Development Checklist

Child’s Record Form 2

3.1 – 5.11 years old

Sociodemographic Profile
Indicate the complete sociodemographic profile of the child.

Child’s Name:______________________________________ Sex: ____ Date of Birth: _____________

month day year
Address: Balamban Cebu VII______________
Barangay Municipality Province Region
Child’s Handedness (Check appropriate box) Right Lef
Both Not yet established
Is the child presently studying? (Check appropriate box) Yes No
If Yes, write name of child’s school/learning center/ day care:__________________________________
Father’s Name: ___________________________________Father’s Age: ________________________
Father’s Occupation: ______________________________ Father’s Educational Attainment: ________
Mother’s Name: __________________________________ Mother’s Age: _______________________
Mother’s Occupation: _____________________________ Mother’s Educational Attainment: _______
Child’s Number of Siblings: __________________________ Child’s Birth Order (1 st, 2nd, 3rd, etc) ______
Republic of the Philippines
Department of Education
Deped Complex, Meralco Avenue, Pasig City
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