Weeks Premature
(put "0" if not premature)

List others assisting with completion of the questionnaire

For ASQ:SE-2™ English

List others assisting with completion of the questionnaire

PLEASE NOTE: by clicking the submit button (below) you are giving your consent to participate in the screening/monitoring program, if you do not wish to participate you need not do anythnig further . 

____ I have read the provided information about the Ages & Stages Questionnaires (ASQ-3), and I wish to have my child(ren) participate in the monitoring program. I will fill out the questionnaires about my child's development and promptly return the completed questionnaires through the online questionnaire completion system.

____ I do not wish to participate. I have read the provided information about the Ages & Stages Questionnaires (ASQ-3) and understand the purpose of this program.

Parent/Guardian Signature

Please Print Parent/Guardian Name

Date

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.