List others assisting with completion of the questionnaire

Appendix J: FY 21 CFCE Ages and Stages Questionnaire and Parental Consent 

Dear Parent/Guardian:

The Massachusetts Department of Early Education and Care (EEC) and The Family Center of Northern Berkshire invite you to complete the Ages & Stages Questionnaires® (ASQ®) with your child.  The ASQ® is a developmental screening tool that provides you with a quick check of your child’s development.  It is easy to use and typically takes about ten minutes to complete.

The ASQ® provides a snapshot of your child’s development and it focuses on what your child can do.  It celebrates your child’s strengths, highlights developmental milestones, and identifies any areas that may need more support.  Regular screenings allow you to learn about your child’s development and to address any questions or concerns you may have about what typical development looks like.  It allows you to participate in the decision-making opportunities related to your child’s early education and care programming, and it provides your program with invaluable knowledge about your child.  Additionally, you may receive an activities sheet filled with ideas on how to extend the learning at home.

You have an opportunity to complete one or both of the following ASQ® developmental screening tools:

1.       Ages & Stages Questionnaires® - Third Edition (ASQ® DEV-3) addresses communication, gross motor, fine motor, problem solving, and personal-social skills.

2.       Ages & Stages Questionnaires®: Social-Emotional - Second Edition (ASQ®:SE-2): addresses self-regulation, compliance, communication, adaptive behaviors, autonomy, affect, and interaction with people.  

The Family Center of Northern Berkshireand EEC collect ASQ® screening data to identify trends and patterns in the early education and care settings in order to better support the programs with resources and professional development opportunities.  EEC is only analyzing the combined scores of all the screening results.  The specific names of children are not included in the analysis. 

ASQ® results are confidential.  BothThe Family Center of Northern Berkshire and EEC follow the Massachusetts confidentiality laws to ensure that your and your child’s personally identifiable information is protected. 

EEC signed a data-sharing agreement with United Way to jointly develop a data platform to analyze the combined data.  The data-sharing agreement ensures that all individuals accessing the data will maintain confidentiality and ensure your and your child’s privacy. 

If you do not wish to have your child’s information entered into the online database, you may decline this option.  Your child may be screened using the ASQ® paper version of the questionnaire, and no information will be shared.

This form requests your permission to participate in the developmental screening process with your child; to enter your child's screening data into an online database; and to share your child’s de-identified screening data with the Department of Early Education and Care (EEC) and any of its designated agents, assigns, partners, contractors, or subcontractors (in this case, United Way).  

Initial the box(es) of the ASQ® that you wish to complete. 

I acknowledge that I have read the information provided by The Family Center and EEC about the ASQ® screening process, and I choose the following option(s):

ASQ® Participation Options

Initial for

ASQ®-3

Initial for

ASQ®: SE-2

I agree to complete the ASQ®, and The Family Center may enter my child’s information into the online database to be shared with EEC for the data summary report.*

I agree to complete the ASQ® andThe Family Center may not enter my child’s information into the online database and may not be shared with EEC for the data summary report.*

I decline to participate in the screening process. 

_________________________________

Name of Child

_________________________________                                        __________________________          

Signature of Parent or Guardian                                                                                Date

_________________________________

Name of Parent or Guardian                    

* The data summary reports will only compile combined scores from all children and will not include the specific names of children.

Please read the text below and click on the “submit button” if you choose to proceed with the Ages & Stages Questionnaires® (ASQ®) screening online via the Family Access Link provided to you The Family Center of Northern Berkshire

I acknowledge that I have read the information provided by the Department of Early Education and Care (EEC) about the ASQ® screening process and choose the following option:

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.