Brookes ASQ | ASQ:SE2 - ASQ-3 English

landing page logo

Early Learning and Family Support, El Dorado County Office of Education

For questions regarding this screening, please contact

Klaudia Silva, Family Engagement Specialist at 530-919-8007 or [email protected]
Rene Line, Program Coordinator, 530-295-2419, [email protected]

Child Date of Birth

Month Day Year

Weeks Premature
(put "0" if not premature)

For ASQ:SE-2™ English

Screening Date

List others assisting with completion of the questionnaire

For ASQ-3™ English

Screening Date

List others assisting with completion of the questionnaire

It is voluntary to participate in this program and at no cost to you. A Family Specialist will share your child's results with you only. Results will remain confidential and will not be shared without your consent.

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.