South East Early Intervention Program - EI
435.381.2667
[email protected]
15 East 600 North Suite B
Castle Dale, Utah 84513

ASQ-3

Welcome to the Utah Department of Health and Human Services, Ages and Stages Questionnaire® (ASQ) program, in partnership with South East Early Intervention!

Because your child's first 5 years of life are so important, we want to help you provide the best start for your child. You've been invited to participate in the ASQ program, to help you keep track of your child's development.  In addition to connecting you to the ASQ, we will also work with you to identify resources, programs and information that are right for your family.

The ASQ is an online developmental screening tool that helps you to:

* understand and support your child’s developmental milestones;

* identify possible delays that may need attention; and

* celebrate your child’s ongoing development.

The questionnaire may be provided every few months. You will be asked to answer questions about things your child can and cannot do at this time. The questionnaire includes questions about your child's emerging communication, social, problem solving and movement skills. 

This developmental screening opportunity is provided by the Department of Health and Human Services (DHHS). DHHS partners with early care and education providers, to ensure all families with young children have access to developmental screening.

Use of Data

Early childhood programs rely on data to inform decisions about effective early childhood policy and services. Data helps DHHS to understand which practices work best and provide evidence to advocate for additional funding to best support Utah families and young children.

Participation in ASQ online is optional. South East EI partners with DHHS to collect basic information about your family and the services provided. DHHS is committed to protecting the personal data it maintains on behalf of its citizens. We look forward to your participation in ASQ and working with you to provide the best start to your child’s life! 

To get started with the ASQ Online Questionnaire, please enter your child's birth date and the number of weeks he or she was born premature below to start the screening. 



(put "0" if not premature)



I am the parent or legal guardian of this child with authority to make healthcare decisions for my child. By clicking submit, I agree to allow data entered through this electronic form to be stored in a secure database for my provider to review.

If I choose not to submit this and share my child’s screening data as stated above, I may request a paper screening option from my child’s provider.

I understand that signing this authorization is voluntary. I understand this authorization will expire upon my child's 18th birthday.

I understand that I may revoke this authorization at any time and the revocation does not apply to any action that has taken place prior to the date I revoke this authorization.

To revoke this authorization, I must make a request in writing and send it to: [email protected].

Note: By clicking "Submit", you are agreeing to both our Family Access End User License Agreement and any other consent or authorization information outlined on this page.

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