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)

List others assisting with completion of the questionnaire

For ASQ-3™ English

List others assisting with completion of the questionnaire

This form requests your permission to participate in the developmental screening process with your child; to enter your child's screening data into an online database; and to share your child’s de-identified screening data with the Department of Early Education and Care (EEC) and any of its designated agents, assigns, partners, contractors, or subcontractors (in this case, United Way).  

Initial the box(es) of the ASQ® that you wish to complete. 

I acknowledge that I have read the information provided by Lunenburg School Linked Services/Coordinated Family & Community Engagement Program] and EEC about the ASQ® screening process, and I choose the following option(s):

ASQ® Participation Options

Initial for

ASQ®-3

Initial for

ASQ®: SE-2

I agree to complete the ASQ®, and Lunenburg School Linked Services/CFCEmay enter my child’s information into the online database to be shared with EEC for the data summary report.*

I agree to complete the ASQ® andLunenburg School Linked Services/CFCEmay not enter my child’s information into the online database and may not be shared with EEC for the data summary report.*

I decline to participate in the screening process. 

_________________________________

Name of Child

_________________________________                                        __________________________          

Signature of Parent or Guardian                                                                                Date

_________________________________

Name of Parent or Guardian                    

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 Lunenburg School Linked Services/Coordinated Family &Community Engagement

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.