Brookes ASQ | ASQ:SE2 - ASQ-3 English

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ECDEC D15
847-963-3450
[email protected]
2800 W Central Rd
Rolling Meadows Illinois 60008
www.ecdec.org

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 (2025-04-30) 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 (2025-04-30) 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.

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