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 questionnaire completion system.  I understand that my child's records will not be released to anyone without my written consent on the Release of Information/Authorization for Use of Disclosure of Protected Health Information (in accordance with Arizona state law, the Privacy Rule of the Health Insurance Portability and Accountability Act of 1986 (HIPAA) and 42 CFR Part 2).  I understand that my child's records will be kept for 5 years and then they will be destroyed.

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