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)

List others assisting with completion of the questionnaire

For ASQ-3™ English

List others assisting with completion of the questionnaire

By proceeding with this questionnaire, you agree to allow the Wallingford Elementary School Pre-K Program to review your answers and follow up with you directly. The Wallingford Elementary School Pre-K Program will communicate screening results and other basic information about your family with your child’s health care provider and other service providers. When appropriate, a copy of the scored questionnaire in full will be shared with your child’s health care or other service provider to improve support for your family.  

Additionally, in partnership with Help Me Grow Vermont, the Wallingford Elementary School Pre-K Program shares developmental screening information with others to provide an overall view of how Vermont’s children are doing and to coordinate support. By clicking “Submit” you are agreeing to share your child’s information and screening results as outlined in the Authorization for Release and Disclosure of Developmental Screening Results. This authorization is voluntary. 

For more details, or if you do NOT wish to participate in this online developmental screening program, please contact us.

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.