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

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. 

Your Participation in the Ages & Stages Questionnaires® (ASQ) Means: 

Ages & Stages Questionnaires® (ASQ) screenings will be completed on your child’s overall developmental skills. These screens will identify your child’s strengths as well as any areas where your child may need practice or support. 

Giving Permission Means: 

• You freely agree to participate in the ASQ screenings. 

• You can change your mind about participating in the ASQ screenings at any time. 

• Oldham County Health Department, an affiliate of Help Me Grow Kentucky, will contact you for future screenings.  You can opt out of these future screenings at any time. 

• You agree to Oldham County Health Department sharing information with your health care provider, Help Me Grow Kentucky, First Steps, and/or local school districts for referrals to services that may help your child. 

• Your child’s ASQ results cannot be released to other persons, or programs without your permission. 

• You always have access to all information collected by Oldham County Health Department about your child. 

• You agree to ongoing communication and screenings through Oldham County Health Department.

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.