Child Date of Birth
Format: yyyy-mm-dd
Child DOB you entered is in the future, are you sure of that? (Please correct the date before proceeding to the next step). Please enter your child's DOB and not the screening date or today's date (Please correct the date before proceeding to the next step). Child DOB you entered is not valid, please format the date like this: YYYY-MM-DD

Weeks Premature
(put "0" if not premature)

For ASQ-3™ English

List others assisting with completion of the questionnaire

For ASQ:SE-2™ English

List others assisting with completion of the questionnaire

I hereby authorize and acknowledge that I am the parent or guardian of this child and will be administering the screening.  I consent to have the Developmental Screening scored.  I understand that I will be contacted by mail or telephone with results and recommendations. I understand that if I am utilizing this tool while school is not in session, I will not receive a follow-up until after school begins again. The screening results will be maintained in a confidential format and will not be released without parent/guardian consent. Utilizing this process does not obligate you to follow-through with any of the options suggested. 

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.