CFCE - North Suburban Child and Family Resource Network/Wakefield Public Schools
781 246 5187
[email protected]
30 Farm Street
Wakefield, Massachusetts 01880
nsfamilynetwork.org

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 (2024-11-21) 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 (2024-11-21) I screened my child and am entering in the responses to a previous screening

List others assisting with completion of the questionnaire

Two Types of ASQ® Developmental Screening Tools Available:You have an opportunity to complete one or both of the following ASQ® developmental screening tool

1 .Ages & Stages Questionnaires® - Third Edition (ASQ® DEV-3) addresses communication, gross motor, fine motor, problem solving,and personal-social skills.

2. Ages & Stages Questionnaires®: Social-Emotional - Second Edition (ASQ®:SE-2): addresses self-regulation, compliance, communication, adaptive behaviors, autonomy, affect, and interaction with people.

Why We Collect ASQ® Data:

North Suburban Child and Family Resource Network and EEC collect ASQ® screening data to identify trends and patterns in the early education and care settings in order to better support the programs with resources and professional development opportunities.EEC is only analyzing the combined scores of all the screening results. The specific names of children are not included in the analysis.

ASQ® results are confidential. Both North Suburban Child and Family Resource Networkand EEC follow the Massachusetts confidentiality laws to ensure that your and your child’s personally identifiable information is protected.

EEC signed a data-sharing agreement with United Way to jointly develop a data platform to analyze the combined data. The data-sharing agreement ensures that all individuals accessing the data will maintain confidentiality and ensure your and your child’s privacy.

If you do not wish to have your child’s information entered into the online database, you may decline this option. Your child may be screened using the ASQ® paper version of the questionnaire, and no information will be shared.

ONLINE CONSENT FORM

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 North Suburban Child and Family Resource Network.

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.