Melba S. Lehner Children's School-Weber State University
(801) 626-6271
[email protected]
1351 Edvalson St. Dept. 1301
Ogden, Utah 84408



(put "0" if not premature)

Screening Date Options

For ASQ-3™ English


For ASQ:SE-2™ English


I am the parent or legal guardian of this child with authority to make healthcare decisions for my child. By clicking submit, I agree to allow data entered through this electronic form to be stored in a secure database for my provider to review.

If I choose not to submit this and share my child’s screening data as stated above, I may request a paper screening option from my child’s provider.

I understand that signing this authorization is voluntary. I understand this authorization will expire upon my child's 18th birthday. I understand that I may revoke this authorization at any time and the revocation does not apply to any action that has taken place prior to the date I revoke this authorization. To revoke this authorization, I must make a request in writing and send it to: Department of Workforce Services, [email protected] Subject Line REVOCATION.

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.