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

Parent Consent to Screen

Ages and Stages Questionnaires

ASQ-3/ASQ: SE-2

The first 5 years of life are very important for your children because this time sets the stage for success in school and later in life. During infancy and early childhood, your child will have many experiences and learn many skills. It is important to ensure that each child’s development proceeds well during this period.

As part of consenting to do the ASQ screenings, I understand that screening information entered online will be shared with the Delaware Department of Education, Office of Early Learning,  the Delaware Department of Public Health and Delaware Health and Social Services  to determine overall developmental trends that will help with budget and resource decisions. Screening results will also be shared with your childcare provider, because they must keep track of completed developmental screenings (required by Delaware STARs) and your district of residence if there is a concern.

­­­­­­­­­­­­­­­­­

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.