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:SE-2™ English

List others assisting with completion of the questionnaire

For ASQ-3™ English

List others assisting with completion of the questionnaire

I consent to the observation, screening and/or assessment of my child.  Screening may include vision, hearing, speech, language, motor, social, emotional and developmental skills according to Early Learning Coalition of Alachua County, Inc. guidelines. I understand that upon completion of the screening/assessment, the results will be shared with me.

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