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

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.