Weeks Premature
(put "0" if not premature)

List others assisting with completion of the questionnaire

For ASQ-3™ English

List others assisting with completion of the questionnaire

CONSENT INFORMATION

Dear Parent/Guardian:

The Massachusetts Department of Early Education and Care (EEC) and the Somerville Family Learning Collaborative (SFLC) invite you to complete the Ages & Stages Questionnaires® (ASQ®) with your child.  The ASQ® is a developmental screening tool that provides you with a quick check of your child’s development.  It is easy to use and typically takes about ten minutes to complete.

The ASQ® provides a snapshot of your child’s development and it focuses on what your child can do.  It celebrates your child’s strengths, highlights developmental milestones, and identifies any areas that may need more support.  Regular screenings allow you to learn about your child’s development and to address any questions or concerns you may have about what typical development looks like.  It allows you to participate in the decision-making opportunities related to your child’s early education and care programming, and it provides your program with invaluable knowledge about your child.  Additionally, you may receive an activities sheet filled with ideas on how to extend the learning at home.

You have an opportunity to complete one or both of the following ASQ® developmental screening tools:

1.      Ages & Stages Questionnaires® - Third Edition (ASQ® DEV-3) addresses communication, gross motor, fine motor, problem solving, and personal-social skills.

2.      Ages & Stages Questionnaires®: Social-Emotional - Second Edition (ASQ®:SE-2): addresses self-regulation, compliance, communication, adaptive behaviors, autonomy, affect, and interaction with people.  

SFLCand EEC collect ASQ® screening data to identify trends and patterns in the early education and care settings in order to better support the programs with resources and professional development opportunities.  EEC is only analyzing the combined scores of all the screening results.  The specific names of children are not included in the analysis. 

ASQ® results are confidential.  BothSFLC and EEC follow the Massachusetts confidentiality laws to ensure that your and your child’s personally identifiable information is protected. 

EEC signed a data-sharing agreement with United Way to jointly develop a data platform to analyze the combined data.  The data-sharing agreement ensures that all individuals accessing the data will maintain confidentiality and ensure your and your child’s privacy. 

If you do not wish to have your child’s information entered into the online database, you may decline this option.  Your child may be screened using the ASQ® paper version of the questionnaire, and no information will be shared.

Please read the text below and click on the “submit button” if you choose to proceed with the Ages & Stages Questionnaires® (ASQ®) screening online via the Family Access Link provided to you by the Somerville Family Learning Collaborative (SFLC).

I acknowledge that I have read the information provided by the Department of Early Education and Care (EEC) about the ASQ® screening process and choose the following option:

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.