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 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.