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Examiner's Notes: Write Down Your Notes, Descriptions and Observation On The Columns Provided

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Examiner’s Notes

Write down your notes, descriptions and observation on the columns provided.

Name of examiner :__________________ Name of examiner :__________________ Name of examiner :__________________


Date administered : __________________ Date administered : __________________ Date administered : __________________
Place of test : ______________________ Place of test : ______________________ Place of test : ______________________

Child’s background (ex. Child’s background (ex. Child’s background (ex.


behavior/health/etc.) behavior/health/etc.) behavior/health/etc.)

_______________________________ _______________________________ _______________________________

_______________________________ _______________________________ _______________________________

_______________________________ _______________________________ _______________________________

_______________________________ _______________________________ _______________________________

Family environment (ex. Health of family Family environment (ex. Health of family Family environment (ex. Health of family
members/family problems/ economic members/family problems/ economic members/family problems/ economic
conditions/etc.) conditions/etc.) conditions/etc.)
_______________________________ _______________________________ _______________________________

_______________________________ _______________________________ _______________________________

_______________________________ _______________________________ _______________________________

_______________________________ _______________________________ _______________________________

Parents’ stimulating activities for the child Parents’ stimulating activities for the child Parents’ stimulating activities for the child
(What are the activities/things that the (What are the activities/things that the (What are the activities/things that the
parents do to help stimulate the child’s parents do to help stimulate the child’s parents do to help stimulate the child’s
development?) develop ment?) develop ment?)
_______________________________ _______________________________ _______________________________

_______________________________ _______________________________ _______________________________

_______________________________ _______________________________ _______________________________

_______________________________ _______________________________ _______________________________

Home environment (ex. Facilities/type of Home environment (ex. Facilities/type of Home environment (ex. Facilities/type of
house/ household items/interaction/etc.) house/ household items/interaction/etc.) house/ household items/interaction/etc.)

_______________________________ _______________________________ _______________________________

_______________________________ _______________________________ _______________________________

_______________________________ _______________________________ _______________________________

_______________________________ _______________________________ _______________________________

Others Others Others

_______________________________ _______________________________ _______________________________

_______________________________ _______________________________ _______________________________

_______________________________ _______________________________ _______________________________

Early Childhood Care and Development (ECCD) Checklist, Child’s Record 2 17

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