Brookes ASQ | ASQ:SE2 - ASQ-3 English

Leduc County - Family Resource Network
7807174372
[email protected]
1101 - 5 Street
Nisku, Alberta T9E 2X3
leduc-county.com

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 (2024-12-21) 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 (2024-12-21) I screened my child and am entering in the responses to a previous screening

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. I will fill out the questionnaire about my child's development and promptly submit the completed questionnaire through this Family Access online questionnaire completion system.

Your personal information is collected by Leduc County under the authority of section 33(c) of the Alberta Freedom of Information and Protection of Privacy Act. It will be used for the purposes for which it is collected. Questions concerning the collection and use of this information can be directed to the Leduc County’s FOIP coordinator at [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.