Southwest Utah Health Department - LHD
435 986 2588
[email protected]
620 South 400 East Ste 400
St. George, Utah 84770
swuhealth.org

Welcome to the Utah Department of Health and Human Services, Ages and Stages Questionnaire® (ASQ) program, in partnership with Southwest Utah Public Health Department!

Because your child's first 5 years of life are so important, we want to help you provide the best start for your child. You've been invited to participate in the Ages & Stages Questionnaires: Social-Emotional, Second Edition (ASQ:SE-2) to help you keep track of your child's social and emotional development. You will be asked to answer questions about some of your child's behaviors. The questionnaire includes questions about your child's ability to calm down, take direction and follow rules, communicate, perform daily activities (e.g., eating, sleeping), act independently, demonstrate feelings, and interact with others.

Please enter your child's birth date and the number of weeks he or she was born premature below to start the screening.



(put "0" if not premature)



I am the parent or legal guardian of this child with authority to make healthcare decisions for my child. By clicking submit, I agree to allow data entered through this electronic form to be stored in a secure database for my provider to review.

If I choose not to submit this and share my child’s screening data as stated above, I may request a paper screening option from my child’s provider.

I understand that signing this authorization is voluntary. I understand this authorization will expire upon my child's 18th birthday.

I understand that I may revoke this authorization at any time and the revocation does not apply to any action that has taken place prior to the date I revoke this authorization.

To revoke this authorization, I must make a request in writing and send it to:[email protected].

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.

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