Weeks Premature
(put "0" if not premature)

List others assisting with completion of the questionnaire

For ASQ:SE-2™ English

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 questiionnaire system. I give permission to ELC of Duval Developmental Health Department to share screening results and referrals (if given) with my child's pediatrician. Participation in this project is voluntary and at no cost to you. 

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.