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

I am completing this Developmental Screening online through the University of Arizona Cooperative Extension, Pinal County for the purpose of evaluating my child's developmental progress. I am aware that after the screening is processed, someone from the developmental screening team will contact me, with the results. I understand the results of the screening may be shared with my child's AHCCCS plan, doctor, First Things First, County, and its partners. I understand the screenings performed are not a medical diagnosis, but only a tool to help keep track of my child’s development as well as possibly uncover early developmental delays which can be followed up with the appropriate resource agency depending on the age of the child. I am aware that I am responsible for following up if a referral for more evaluation is recommended.

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