Brookes ASQ | ASQ:SE2 - ASQ-3 English

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Oakland County Help Me Grow
www.greatstartoakland.org
844.456.5437
www.facebook.com/greatstartOC

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 (2024-11-23) 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 (2024-11-23) I screened my child and am entering in the responses to a previous screening

List others assisting with completion of the questionnaire

Participation in this project is voluntary and at no cost to you. Your child's results are confidential and will not be shared outside of Help Me Grow-Oakland Early Childhood data system. Your child's non-identifying information will also be combined with that of others in this program for learning purposes. By completing the online ASQ, you give your consent to participate. We will send your child's results by email. Based on these results, we may contact you about early childhood services in which your child may be eligible.

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