Brookes ASQ | ASQ:SE2 - ASQ-3 English

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El Dorado County Community Hubs
www.eldoradocommunityhubs.com

For questions regarding this screening, please contact your Community Hub Family Specialist
or Rene Line, Early Learning and Family Support at EDC Office of Education,
530-295-2419, [email protected]

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 (2024-12-03) 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 (2024-12-03) I screened my child and am entering in the responses to a previous screening

List others assisting with completion of the questionnaire

It is voluntary to participate in this program and at no cost to you. A Family Specialist will share your child's results with you only. Results will remain confidential and will not be shared without your consent.

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.