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DNV: GRUPO: Record Form NÚMERO DO PAR: TM Child's name: Bayley Sex: M F ID #: Examiner's name: Scales of Infant and School/Child care program: Toddler Reason for referral: THIRD EDITION Subtest Summary Scores Calculate Age and Start Point Total Conf. Years Months Scaled Composite Percentile Interval Days Raw Subtest Score Score Score Rank ( %) Date Tested Cognitive (Cog) Date of Birth Use Table A.5 Language (Lang) Age Receptive Communication (RC) Expressive Communication (EC) Age in Months Years X 12 and Days + months Sum Adjustment for Adjust through Use Table A.4 Prematurity 24 months Motor (Mot) Adjusted Age Fine Motor (FM) Start Point Calculate start point Gross Motor (GM) according to chart below Sum Start Point Use Table A.4 Age 16 days-1 month 15 days A Social-Emotional (SE) 1 month 16 days-2 months 15 days B Use Table A.5 2 months 16 days-3 months 15 days C Adaptive Behavior 3 months 16 days-4 months 15 days D *Communication (Com) 4 months 16 days-5 months 15 days E Community Use (CU) 5 months 16 days-6 months 15 days F Functional Pre-Academics (FA) 6 months 16 days-8 months 30 days G 9 months 0 days-10 months 30 days H Home Living (HL) 11 months 0 days-13 months 15 days I *Health and Safety (HS) 13 months 16 days-16 months 15 days *Leisure (LS) 16 months 16 days-19 months 15 days K *Self-Care (SC) 19 months 16 days-22 months 15 days L *Self-Direction (SD) 22 months 16 days-25 months 15 days M *Social (Soc) 25 months 16 days-28 months 15 days N *Motor (MO) (GAC) 28 months 16 days-32 months 30 days Sum 33 months 0 days-38 months 30 days P *For children younger than one year, the GAC is calculated Use Table A.6 39 months 0 days-42 months 15 days Q using only those skill areas indicated by an asterisk. ISBN 015402723-5 PEARSON Copyright © 2006, 1993, 1984, 1969 by NCS Pearson, Inc. PsychCorp All rights reserved. Printed in the United States of America.