Child Date of Birth
Format: yyyy-mm-dd
Child DOB you entered is in the future, are you sure of that? (Please correct the date before proceeding to the next step). Please enter your child's DOB and not the screening date or today's date (Please correct the date before proceeding to the next step). Child DOB you entered is not valid, please format the date like this: YYYY-MM-DD

Weeks Premature
(put "0" if not premature)

For ASQ-3™ English

List others assisting with completion of the questionnaire

For ASQ:SE-2™ English

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.