Brookes ASQ | ASQ:SE2 - ASQ-3 English

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Birth to Three Early Intervention Program
Hope Sanson, Part C Data Manager
[email protected]
410 Federal Street
Dover, Delaware 19901
https://dhss.delaware.gov/dhss/dph/birthtothree/index.htm

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 (2024-11-21) 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 (2024-11-21) I screened my child and am entering in the responses to a previous screening

List others assisting with completion of the questionnaire

By giving my consent, I understand that ASQ screening results will be shared with:

· The Delaware Department of Education (DDOE) and the Division of Public Health (DPH) within Delaware Health and Social Services (DHSS) to better support my child.

· My child care program who is required by law to track completed developmental screenings to help better support my child.

· The Birth to Three Early Intervention Program (B23) or my school district of residence and/or school district where my child care is located because they review the screenings and help with next steps.

I also understand that I will be contacted with results via email, US mail, or phone call to assist with follow-up.

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.