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

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.

o 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.