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)

For ASQ-3™ English

List others assisting with completion of the questionnaire

For ASQ:SE-2™ English

List others assisting with completion of the questionnaire

We are committed to your privacy and the privacy of your child.  The developmental information you enter in ASQ Online may only be viewed by Gold Creek staff that have permission to access your account.  Your child’s name and date of birth may be viewed by the REACH Infant Learning Program Director, since that program supports our use of the ASQ Online.  However, that and all other information is confidential and will only be shared with others with your written consent.  

The State of Alaska Early Intervention/Infant Learning Program (EI/ILP) has provided funding for this project to allow access to developmental screening for all families.  The State EI/ILP staff will be tracking the number of children who are screened but will not be able to view any identifying information.  All collected information is protected under the Family Education Rights and Privacy Act (FERPA) and Health Insurance Portability and Accountability Act (HIPAA).

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.

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.