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

Our new online ASQ system allows us to save paper and time.

PARENTS & CAREGIVERS, PLEASE USE THE CHILDCARE CENTERS ADDRESS WHEN ENTERING AN ADDRESS FOR CHILD’S INFORMATION.

Important Note: The American Academy of Pediatric states that developmental screening should be given at 9, 18, and 30 months of age and/or every 6 months. Therefore, if your child is within these developmental stages they will be screened accordingly.

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.

By clicking “Submit” you are attesting to the following; “I have read and understand the information about the Ages & Stages Questionnaires (ASQ-3) Screener, and I give the Coalition Staff, Child Care Provider and/or teacher permission to screen my child(ren).”

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.