Brookes ASQ | ASQ:SE2 - ASQ-3 English

Early Learning Coalition of Seminole
(407)960-2481
280 Hunt Park Cove
Longwood, FL 32750
www.seminoleearlylearning.org

Child Date of Birth

Month Day Year

Weeks Premature
(put "0" if not premature)

For ASQ-3™ English

Screening Date

I am screening my child today (2024-11-26) I screened my child and am entering in the responses to a previous screening

List others assisting with completion of the questionnaire

For ASQ:SE-2™ English

Screening Date I am screening my child today (2024-11-26) I screened my child and am entering in the responses to a previous screening

List others assisting with completion of the questionnaire

Parents,

While visiting the ELC of Seminole, the ASQ-3 is discussed in detail, with the option to decline. By completing this questionaire you are consenting to future ASQ-3 screenings conducted by your child's provider or the Early Learning Coalition of Seminole. The results from the questionaire are confidential and only accessable by the Early Learning Coalition of Seminole.

Providers,

Please let parents know as you are conducting ASQ-3 on the children in your center, assuing they have consented to this service.

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.