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 have read the provided information about the Ages & Stages questionnaires, and I wish to have my child participate in the online screening program. If I was referred by a childcare center, I understand that my results will be shared with the center. I also understand de-identified results will be compiled and shared with other entities* for evaluative and research purposes. 

**Other Entities may include, but are not limited to:

Early Learning Alliance

Department of State Health Services

University of Texas, Austin

Prevention Early Intervention  

My Health My Resources (MHMR) Tarrant County

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