FORM C.

MULTI-FACTORED ASSESSMENT TOOL (MFAT)

Learner’s LRN:
Code:
DIRECTIONS: Check () YES if the child performed the task, or the item indicated was observed. If not, check
NO and write in the next column the intervention/s made to address the difficulty of the learner on the given
task/activity.

TIME STARTED: _____________________ TIME ENDED: _______________________

Activity 1 Title: LET’S TALK

ITEM
ASSESSMENT ACTIVITY YES NO INTERVETION/S
CODE
Time Started: _________________
Hello, good morning/good afternoon!

COM- Note: The teacher drops a bunch of keys on the

AU-1 floor to produce sounds.

1. Turns head to source when sound is heard

Note: First, the teacher introduces her/himself.
COM- What is your name?
EL-2
2. Tells one’s name/ identifies oneself
Note: The teacher taps the table.
Do you hear the tapping sound on the table?
COM-
AU-3
3. Responds to or nods head appropriately
when spoken to
Repeat it.
COM-
AU-4
4. Repeats table tapping patterns correctly
Do the following:
You stand
COM- Turn around
RL-5 Sit down

5. Recognizes two to three word instructions

Note: Observed in item 5
COM-
RL-6
6. Responds to two-word combination
Who are the members of your family? What
COM- are their names?
EL-7
7. Calls family members by name
Tell me about your family.
COM-
EL-8 8. Tells stories to peers/classs and teacher
coherently
Answer the following questions:
a. What do you do before going to school?
b. What are the things you see in school?
COM-
c. Who are in school?
EL-9
d. What do you do in school?

9. Answers wh-questions
© November 2017, Department of Education. For NTOT.

Page 1 of 20
Page 2 of 20
 FORM C. MULTI-FACTORED ASSESSMENT TOOL (MFAT)

Activity 1 Title: LET’S TALK

ITEM
ASSESSMENT ACTIVITY YES NO INTERVETION/S
CODE
Note: The teacher gets three (3) objects from the box one at a time.
(ball, pencil, book)
COM-
RL-10 What is this?

10. Identifies familiar objects when presented

Describe it. (ball, pencil, book)
COM-
EL-11 11. Describes simple and familiar objects

Note: Place the letters and number cards on the table.

(a,b,w,r,s,t,1,2,3,4,5)
COM-
RL-12 Pick the letters.

12. Picks up the letters

What is the sound of a motorcycle?
COM-
SP-13 13. Makes random non-speech sounds (e.g. wooh, wooh, etc.)

Note: The teacher reads the words and let the child answer the
following questions:

COM- Identify the initial sound of the words: ask, act, and.
RL-14 Identify the medial sound of the words: pat, mat, bat.
Identify the final sound of the words: Ana, Aga, Eva.

14. Discriminates initial, medial and final sounds

Repeat what I will say, :My Teacher, My Hero”

COM- Indicator: Repeats the sentence

EL-15
15. Imitates words/phrases and/or local TV/radio commercial

Note: Let the child read the words.

COM- Read the following words: is, are, has, for, give, his.
RL-16
16. Recognizes pre-primer and primer sight words

Recite/sing any nursery rhyme that you know.

COM-
EL-17 17. Recites common nursery rhymes

© November 2017, Department of Education. For NTOT.

FORM C. MULTI-FACTORED ASSESSMENT TOOL (MFAT)

Activity 1 Title: LET’S TALK

ITEM
ASSESSMENT ACTIVITY YES NO INTERVETION/S
CODE
COM- Note: To be observed during the conversation
SP-18

Page 3 of 20
 18. Prefers talking rather than using gestures and physical
communication

Note: To be observed during the conversation

COM-
EL-19 19. Answers in complete sentence when asked

Note: To be observed during the conversation

COM-
EL-20 20. Express thoughts or ideas correctly

Note: To be observed during the conversation

COM-
SP-21
21. Speaks in an articulated manner in (e.g. without stuttering)
Note: To be observed during the conversation
COM-
VO-22
22. Controls volume of voice when in conversation
Note: To be observed during the conversation
COM-
VO-23
23. Speaks with voice quality when in conversation
Note: To be observed during the conversation
COM-
VO-24 24. Speaks with uninterrupted flow of sounds, words, syllables
and phrases
Do you feel tired? hungry? thirsty? need to go to the toilet?
COM- What do you want to do?
EL-25
25. Expresses basic needs and/or wants (verbal, gestural, sign)
Time Ended: ___________________

ITEM Not
OBSERVATION CHECKLIST YES NO Remarks
CODE Observed
1. Does the learner have difficulty expressing
CM-
needs orally?
34

2. Does the learner have difficulty listening

H-6 when spoken to?

3. Does the learner have difficulty recognizing

H-19 commands?

4. Does the learner turns or tilts head to use

H-25 one eye only in performing tasks?

© November 2017, Department of Education. For NTOT.

FORM C. MULTI-FACTORED ASSESSMENT TOOL (MFAT)

Activity 2 Title: TREASURE BOX

ITEM
ASSESSMENT ACTIVITY YES NO INTERVETION/S
CODE
Time Started: _________________
COG- Note: Teacher gets 3 objects from the treasure box and place them

Page 4 of 20
 on the table.

NU- From your left, which object is in the middle? last? first?
26
26. Recognizes position of objects – first / middle / last

Note: Teacher gets cut-out pictures from the box and lay them
down on the table.

COG- Here are cut-out pictures of different objects. Group them

SA-27 according to shapes (triangle, rectangle, square and circle)

27. Sorts objects based on shapes

Arrange the cut-out pictures of objects from smallest to biggest.

COG-
SA-28 28. Arranges objects according to size from smallest to biggest

I have here a picture, get another picture on the table that is of

the same size with the one I am holding.
COG-
SA-29
29. Matches objects according to size

Put together cut-out pictures that are red.

COG- Put together cut-out pictures that are small.

SA-30
30. Sorts objects based on 2 attributes (e.g. color & size)

Get three shapes with the same color.

COG-
SA-31 31. Matches 2 – 3 colors

Name the letters of the alphabet.

COG-
RD-32 32. Names the letters of the alphabet

© November 2017, Department of Education. For NTOT.

FORM C. MULTI-FACTORED ASSESSMENT TOOL (MFAT)

Activity 2 Title: TREASURE BOX

ITEM
ASSESSMENT ACTIVITY YES NO INTERVETION/S
CODE
Time Started: _________________
Note: Teacher places letters M, R, S, T, A, and P on the table and
prepares the matching small letters with two distractor letters.

COG- I have here 6 big letters of the alphabet. Get the small letters on
SA-33 the table and match them with the big letters.

33. Matches big with small letters

COG- Count from one to twenty.

NU-
34 34. Rote counts 1 to 20.

Page 5 of 20
 Get three number cards from the treasure box one at a time and
COG- tell me what number it is.
NU-
35 35. Identifies numbers from 1 to 20

Note: Place the number cards on the table. (2, 5, 7)

Get the popsicle sticks from the treasure box.

COG-
NU- Show the number of popsicle sticks that matches the number on
36 the card.

36. Associates numbers 1 to 10 with objects

Using popsicle sticks, add the following:

COG- 1) 8 + 2 = ___
NU- 2) 5 + 5 = ___
37 3) 1 + 9 = ___

37. Adds objects to get a sum of 10

Using popsicle sticks, subtract the following:

COG- 1) 11 - 1 = ___
NU- 2) 12 - 2 = ___
38 3) 13 - 3 = ___

38. Subtracts objects to get a difference of 10.

Note: Follow the same instruction for the P10, P5, and P1 coins.
COG-
NU- Get a 20-peso bill from the treasure box.
39
39. Identifies Philippine Peso Bills and Coins
© November 2017, Department of Education. For NTOT.

FORM C. MULTI-FACTORED ASSESSMENT TOOL (MFAT)

Activity 2 Title: TREASURE BOX

ITEM
ASSESSMENT ACTIVITY YES NO INTERVETION/S
CODE
What is/are the missing number/s?
(1, 2, ____, 4, 5, ____
2, 4, 6, ____, 10, 12…
COG- 3, 6, ____, ….
RE-40 5, ____, 15…)

40. Follows number patterns

Note: Teacher sets the time at 3:00, 7:00 and 9:00.

COG-
Look at the clock I am holding. Tell me what time it is.
NU-
41
41. Identifies time by the hour

COG- Identify the events in the pictures. Which do you think comes

Page 6 of 20
 first? last? Arrange the pictures.
RE-42
42. Sequences picture story of 4 to 6 events

Look at the pictures again. Tell me which event happened in the

morning? afternoon? night?
COG-
RE-43
43. Identifies time concept of the day (morning, afternoon, night)

Arrange the puzzle to complete the picture.

COG-
RE-44 44. Completes simple puzzles

Note: In case the learner was not able to do the puzzle, the
teacher shows the guide picture.

COG- Point the head, neck, shoulder, hands, fingers, legs, knees and
CL-45 toes.

45. Identifies body parts.

Which part of the body is for seeing? hearing? tasting? feeling?

smelling?
COG-
CL-46
46. Identifies five senses

© November 2017, Department of Education. For NTOT.

Page 7 of 20
 FORM C. MULTI-FACTORED ASSESSMENT TOOL (MFAT)

Activity 2 Title: TREASURE BOX

ITEM
ASSESSMENT ACTIVITY YES NO INTERVETION/S
CODE
Look at these two pictures. What are the differences between
these pictures?
COG-
RE-47
47. Identifies what is different in the picture

What is missing in the picture?

COG-
RE-48 48. Identifies what is missing in the picture

Whoa are the members of your family?

COG-
RT-49 49. Name members of the family.

Note: Observe the reaction of the learner and ask the learner
which of the two books he likes most?
COG-
Get 2 books from the treasure box.
RD-50

50. Exhibits interest in books

Time Ended: ________________

ITEM Not
OBSERVATION CHECKLIST YES NO Remarks
CODE Observed
1. Does the learner hold the materials too
V-1 close to his/her eyes?

2. Does the learner use his/her fingers to

V-7 maintain place of words/letters/lines while
reading?
3. Does the learner rub eyes in an effort to see
V-20
better?
4. Does the learner blink continuously?
V-24
5. Does the learner squint, cover or close
V-41
his/her eyes while performing a given task?
6. Does the learner have difficulty associate
Cg-3 numbers with symbols?

7. Does the learner have difficulty

Cg-5 remembering things heard?

8. Does the learner have difficulty giving

Cg-13 appropriate response to questions?

9. Does the learner have difficulty following a

Cg-17
series of directions?
© November 2017, Department of Education. For NTOT.
FORM C. MULTI-FACTORED ASSESSMENT TOOL (MFAT)

Page 8 of 20
ITEM Not
OBSERVATION CHECKLIST YES NO Remarks
CODE Observed
10. Does the learner have difficulty recalling
Cg-26
information in the past?
11. Does the learner have difficulty giving
Cg-31 appropriate response to interview
questions?
12. Does the learner have difficulty responding
Cg-9
orally in identifying one-word objects?
13. Does the learner repeat, omit or adds
Cg-10
words when she/he answers?
14. Does the learner have difficulty responding
Cg-9
orally in identifying one-word objects?
15. Does the learner repeat, omit or adds
Cg-10
words when she/he answers?
16. Does the learner have difficulty
Cg-21 remembering names of body parts and
senses?

Activity 3 Title: MY DAILY ROUTINE

ITEM
ASSESSMENT ACTIVITY YES NO INTERVETION/S
CODE
Time Started: ________________
Suppose you are talking a bath. Show me how you do it.
DLS-
GH-
51
51. Takes a bath

Show me how you brush your teeth.

DLS-
GH-
52
52. Brushes own teeth.

Note: Teacher gives a polo shirt/blouse and shorts/skirt/pants

and ask the learner to stand and wear it.
DLS-
Show me how you put on your clothes.
DR-53

53. Put on clothes.

(If the learner does not button the clothes, the teacher may
instruct the learner to do the instruction below.)

DLS- Show me how to button your polo shirt/blouse.

DR-54
Then show me how you unbutton your shirt/blouse.

54. Buttons and unbuttons clothes

© November 2017, Department of Education. For NTOT.
FORM C. MULTI-FACTORED ASSESSMENT TOOL (MFAT)

Activity 3 Title: MY DAILY ROUTINE

ITEM
ASSESSMENT ACTIVITY YES NO INTERVETION/S
CODE
Time Started: ________________
DLS- Note: Let the learner stand and demonstrate how to zip and

Page 9 of 20
 unzip pants/skirts/shorts.

Show me how to zip and unzip your pants/skirts/shorts.

DR-55

55. Zips and unzips pants

Show me how you take off your clothes.

DLS-
DR-56 56. Takes off clothes.

Show me how you put on your shoes.

DLS-
DR-57 57. Put on shoes.

Note: If the learner is already wearing shoes with lace, ask the
child to untie first, then tie.

DLS- Show me how you tie your shoe lace.

DR-58
Then untie your shoe lace.

58. Ties and unties shoe lace

Note: Teacher will let the child demonstrate.
DLS-
GH- Show me how to comb or brush your hair.
59
59. Combs or brushes hair
Note: Give the learner a handkerchief or a tissue paper.
DLS-
Show me how you wipe or blow your nose using the tissue
GH-
60
paper or handkerchief.

60. Wipes / blows nose properly

Note: Bring the child to the washroom.
If there is none, provide a pail of water, dipper, basin, soap and
DLS- towel.
GH-
61 Wash your hands, then dry them.

61. Washes and dries hands

Note: Provide the learner with plate, spoon, fork, glass and
placemat.
DLS-
Show me how to set the table.
FE-62

62. Sets the table

© November 2017, Department of Education. For NTOT.

FORM C. MULTI-FACTORED ASSESSMENT TOOL (MFAT)

DLS- Note: Provide the learner with bread, sandwich spread in a bottle, and
FE- spoon.
63 If the child is not exposed to preparing a sandwich, he/she may be
interviewed on other meals that he/she has prepared like cooking
egg/camote, etc.

Show me how to prepare a sandwich.

Page 10 of 20
 63. Prepares a 2-3 step meal
Note: The assessor will provide any container that the learner will open
and close. This may be observed while the child is preparing the meal.
DLS-
FE- Show me how to open bottles/jars and other food containers, then
64 close them

64. Opens and closes bottles/jars and other food containers boxes/food
Note: The assessor will provide the table napkin/sandwich wrapper to
the learner.
DLS-
Wrap your sandwich.
FE-
65
Now you’re ready to eat your sandwich. Unwrap it.

65. Wraps/unwraps
Note: The assessor will verify this with the parent through observation
DLS-
FE- Do you consume the food on plate?
66
66. Consumes food on one’s plate
Note: Validate through interview with the parent.
DLS-
FE- Can you serve yourself from a serving plate? Show me how.
67
67. Serves self from serving plate
Note: The assessor will provide the eating utensils to be used. Let the
learner pretend using eating utensils.
DLS-
FE- Do you know how to use your eating utensils properly? Show me
68 how.

68. Uses eating utensils properly

DLS- Show me how you drink from a cup/glass/bottle.
FE-
69 69. Drinks from a cup/glass/bottle
© November 2017, Department of Education. For NTOT.
FORM C. MULTI-FACTORED ASSESSMENT TOOL (MFAT)

Note: Validate through interview with the parents.

Do you clear your own place after eating at the table? Show me
how.

70. Clears own place (at table) after eating

Note: Compare answer with Activity 1 item no. 25. This may be
observed during the duration of the assessment.

Do you tell your teacher if you need to go to the toilet/CR?

71. Expresses the need to go to the toilet

Note: Validate through interview with the parents. This may be
observed during the duration of the assessment.

Do you flush the toilet after using it?

Page 11 of 20
 72. Flushes toilet after use
Note: Validate through interview with the parents. This may be
observed during the duration of the assessment.

After using the toilet, do you wash your hands?

73. Cleans self after toileting

Note: Show 6 danger signs/symbols:
 Slippery when wet
 High voltage
 Poisonous/toxic
 Flammable
 Road under construction
 Falling debris

Are you familiar with these symbols?

What does this symbol mean? When you see this, what should
you do?

74. Identifies danger signs and symbols

Here are pictures of broken glasses, high places, streets or

sharp and pointed objects. What will you do if you see these?
Why?

75. Keeps out of danger, broken glass/high places, streets or

sharp and pointed objects

Time Ended: _________________

© November 2017, Department of Education. For NTOT.
ITEM Not
OBSERVATION CHECKLIST YES NO Remarks
CODE Observed
1. Does the learner have difficulty in dressing?
M-35
2. Does the learner have difficulty going to the
M-36 toilet independently?

3. Does the learner have difficulty

accomplishing tasks using his/her fine
M-37 motor skills (e.g. unwrapping, shoe lacing,
opening of bottle, etc.)

4. Does the learner have difficulty in tracing

M-38 activities?

5. Does the learner have difficulty holding the

M-39 scissors?

6. Does the learner have difficulty coloring

M-40 within the lines?

FORM C. MULTI-FACTORED ASSESSMENT TOOL (MFAT)

Page 12 of 20
 Activity 4 Title: WHETHER WEATHER
ITEM
ASSESSMENT ACTIVITY YES NO INTERVETION/S
CODE
Time Started: ________________
Do you play with your friends? What games do you play?
SEB-
SS-76 76. Plays with peers

Note: Interview the teacher adviser if the learner can follow rules
during games.
SEB-
SS-77
77. Follows rules and regulations.

When is the best time to play with friends? Why?

SEB-
SS-78 78. Participates in the conversation

Note: Interview the teacher adviser.

SEB-
What do you do if you lose/win? Why?
SS-79

79. Shows sportsmanship

I have here pictures of different faces. Which of these shows the
SEB- feeling when you win? lose?
SS-80
80. Expresses appropriate emotions
© November 2017, Department of Education. For NTOT.
FORM C. MULTI-FACTORED ASSESSMENT TOOL (MFAT)

Activity 4 Title: WHETHER WEATHER

ITEM
ASSESSMENT ACTIVITY YES NO INTERVETION/S
CODE
Note: Let the learner name at least three friends.
SEB-
How many friends do you have? Name them.
SS-81

81. Makes friends easily

What activities does your mother/father do at home? Show
me how.
SEB-
SS-82
82. Imitates adult activities

Do you have personal belongings? Name some of them.

SEB-
ES-83
83. Identifies personal belongings.
Note: Free hand drawing.

SEB- How many are you in the family? Draw the members of your
ES-84 family. Encircle where you are. (Items number 9 and 10)

84. Identifies self as a member of a family/cultural group

Note: The teacher observes the behavior of the learner while
doing the activity number 9.
SEB-
ES-85
85. Shows initiative to work on tasks

Page 13 of 20
 Note: The teacher gives constructive criticisms on the drawing.
SEB- Refer to item number 9.
ES-86
86. Accepts criticisms positively
Note: Based on the reaction of the learner on item number 11.
SEB-
ES-87
87. Shows self-control
Note: Prior knowledge of the teacher on the learner should be
noted.
SEB-
ES-88
88. Engages in communication with others

Note: The courteous expressions used by the learner.

How do you greet your teacher in the:

a) Morning?
SEB-
b) Afternoon?
SS-89

When you receive a gift, what will you say?

89. Uses courteous expressions appropriately

© November 2017, Department of Education. For NTOT.
FORM C. MULTI-FACTORED ASSESSMENT TOOL (MFAT)

Activity 4 Title: WHETHER WEATHER

ITEM
ASSESSMENT ACTIVITY YES NO INTERVETION/S
CODE
If you accidentally bump somebody, what will you say?
SEB-
SS-90
90. Apologizes when necessary.
Note: This can be observed during the administration. Does the
learner pay attention to someone who is talking?
SEB-
SS-91
91. Pays attention to someone talking

If you have a difficulty homework, what will you do?

SEB-
SS-92
92. Seeks or accepts help when he/she needs it.
Prior knowledge of the teacher on the learner should be noted.
SEB-
SS-93 93. Waits for one’s turn

Note: If not observed during the assessment, validate from the

teacher.
SEB-
SS-94
94. Displays sense of humor

Prior knowledge of the teacher on the learner should be noted.

SEB-
SS-95
95. Leads a group activity
Prior knowledge of the teacher on the learner should be noted.
SEB-
SS-96
96. Asks permission to use things owned by others
Prior knowledge of the teacher on the learner should be noted.
SEB-
SS-97
97. Seeks older friends
SEB- Prior knowledge of the teacher on the learner should be noted.

Page 14 of 20
SS-98
98. Prefers working alone
Note: The teacher should act as one of the characters in the role
playing.

I have four pictures here. Pick one and let’s act it out.
SEB-
a. At home – mother cooking
SS-99
b. School – teacher writing on the board
c. Playground – boy dribbling a ball

99. Participates in role play

© November 2017, Department of Education. For NTOT.
FORM C. MULTI-FACTORED ASSESSMENT TOOL (MFAT)

Activity 4 Title: WHETHER WEATHER

ITEM
ASSESSMENT ACTIVITY YES NO INTERVETION/S
CODE
Note: Validate with the teacher.
SEB-
If one of your classmates has no “baon”, what
ES-
100
should you do?

100. Displays sensitivity to the feelings of others

Time Ended: _________________

ITEM Not
OBSERVATION CHECKLIST YES NO Remarks
CODE Observed
1. Does the learner have difficulty
B-2 concentrating on given tasks?

2. Does the learner have difficulty staying on

B-4 his/her seat during the activity?

3. Does the learner have short attention

B-16 span?

4. Is the learner easily distracted with

B-15 materials for the activity?

5. Does the learner easily get frustrated when

B-22 s/he has difficulty performing tasks?

6. Does the learner have difficulty identifying

B-27 things used for personal hygiene?

7. Does the learner have difficulty giving

appropriate response to questions about
B-28
his/her feelings in given situations?

8. Does the learner have difficulty displaying

interest in activities related with people,
B-29
friends and play?

B-30 9. Does the learner have difficulty articulating

Page 15 of 20
 in expressing his/her thoughts?

10. Does the learner have difficulty giving

appropriate response to questions about
B-32
his/her feelings in given situations?

11. Does the learner shout during the activity?

B-33

© November 2017, Department of Education. For NTOT.

FORM C. MULTI-FACTORED ASSESSMENT TOOL (MFAT)

Activity 5A Title: WORK OF HANDS

ITEM
ASSESSMENT ACTIVITY YES NO INTERVETION/S
CODE
Time Started: _________________
I have here a whole sheet of bond paper. Fold
(MSF- it once in any direction.
101)
101. Folds paper into a shape
Then, tear the paper following the fold you
made.
(MSF-
102)
102. Tears papers in simple shapes

Here are pictures of a ball and a glass.

Trace the broken, straight, and curve lines.

(MSF-
(For item 17-18)
103)

103. Traces broken-straight and curved lines.

104. Traces continuous-straight and curved

(MSF-
lines
104)

Color them.
(MSF-
105) 105. Colors objects

Cut the lines of the glass you traced and

colored (Items 20-22)
(MSF-
106)
106. Cuts paper in straight direction

(MSF- 107. Cuts paper in curved direction

107)
(MSF- 108. Cuts pictures within a given line
108)
Draw a house using different shapes.
(MSF-
109) 109. Draws a combination of shapes

(MSF- Note: Observe whether the learner can hold a

110) pencil/drawing tool using a tripod grip while

Page 16 of 20
 drawing a house.

110. Holds pencil and a drawing tool using a

tripod grip

Copy these letters (B, G and R) on your paper.

(MSF-
111) 111. Copies letters

Time Ended: ____________________

© November 2017, Department of Education. For NTOT.
FORM C. MULTI-FACTORED ASSESSMENT TOOL (MFAT)

ITEM Not
OBSERVATION CHECKLIST YES NO Remarks
CODE Observed
1. Does the learner display poor eye-hand
M-8 coordination?

2. Does the learner have difficulty following

M-11 instructions in performing motor activities?

3. Does the learner have difficulty in

M-12 balancing?

4. Does the learner drool excessively? Does

M-23 saliva come out of the learner’s mouth?

Activity 5B Title: LET’S GET PHYSICAL!

ITEM
ASSESSMENT ACTIVITY YES NO INTERVETION/S
CODE
Time Started: _________________
Stand properly for 5 seconds.
(MSG
-112)
112. Stands with normal stance
Stand on one foot without support with your
eyes closed for 10 seconds.
(MSG
-113)
113. Stands on one foot without support for 10
seconds with eyes closed
Stand on one foot, then tip toe.
(MSG
-114)
114. Stands on one foot and on tiptoe
Now, march in place for five seconds.
(MSG
-115) 115. Marches in place

(MSG Note: Bring the learner to the area where the

-116) straight line marking is.

Walk forward on the straight line.

116. Walks in a straight line with correct

stepping pattern

Page 17 of 20
 Now, step backward. Then take three steps
sideward (R/L).
(MSG
-117) 117. Walks sideward and backwards with
correct stepping pattern

Hop in place three times.

(MSG
-118)
118. Hops in place
© November 2017, Department of Education. For NTOT.
FORM C. MULTI-FACTORED ASSESSMENT TOOL (MFAT)

Activity 5B Title: LET’S GET PHYSICAL!

ITEM
ASSESSMENT ACTIVITY YES NO INTERVETION/S
CODE
Note: Teacher points where to start.

(MSG Skip three times following the line.

-119)
119. Skips within a given path

Gallop five steps sideward (R/L).

(MSG
-120)
120. Gallops sideward
Show me your highest jump. How about your
(MSG longest jump.
-121)
121. Jumps for distance and for a height
Note: Arrange the 3 chairs 1 meter away from
each other. Place the ball on the floor 1 meter
away from the last chair. Tell the learner to run
passing through the chairs without tumbling
and ask him/her to pick up the ball and back to
the starting point going through the same
obstacle. Remind the learner to be careful.
(MSG
(Items 11-12)
-122)

Run passing the three chairs in zigzag manner,

get the ball and run back in the same way. Be
careful.

122. Runs at a given distance and picks up a ball

an obstacle course.
Note: Stand at least 3 meters away from the
learner.
(MSG
-123) Catch the ball and throw it back to me.

123. Throws and catches a ball

Kick the ball forward. This time, kick the ball
(MSG sideward (R/L).
-124)
124. Kicks forward and sideward
(MSG Note: Bring the learner to the stairs.
-125)
Go upstairs with one hand holding the rail,

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 then go down.

This time, go up and down the stairs without

holding the rail.

125. Climbs upstairs and goes downstairs with

one hand holding the rail and without
holding the rail.
Time Ended: ___________________
© November 2017, Department of Education. For NTOT.
FORM C. MULTI-FACTORED ASSESSMENT TOOL (MFAT)

ITEM Not
OBSERVATION CHECKLIST YES NO Remarks
CODE Observed
1. Does the learner have difficulty in dressing?
M-35
2. Does the learner have difficulty going to the
M-36 toilet independently?

3. Does the learner have difficulty

accomplishing tasks using his/her fine
M-37 motor skills (e.g. unwrapping, shoe lacing,
opening of bottle, etc.)

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© November 2017, Department of Education. For NTOT.

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