Weeks Premature
(put "0" if not premature)

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. If my child attends a partner early learning center their screening results will automatically be shared with their teachers. Their teachers will share the results of the screenings with you. Your information is not shared with anyone else without your consent. 

OberlinKids Community Collaborative Confidentiality Statement 

Agencies who conduct services as members of the OberlinKids Collaborative are bound by a collaborative confidentiality policy that complies with federal, state, and local laws as well as individual agency policies to protect the privacy of client information stored in a collaborative database or discussed as part of case management and service referral. This policy ensures OberlinKids can:

• Improve the quality of services and allow for an individualized service plan to meet each family’s needs.

• Help us to identify appropriate resources while minimizing data collection redundancies and client frustration.

• Use of non-identifying information is to track program outcomes, allocate resources, and/or pinpoint unfilled needs to plan for new services, as well as, create reports for release to the community about the progress of the collaborative's efforts, and for potential funding opportunities.

As a client receiving services from an OberlinKids Collaborative Partner/Advocate you have the following rights as they pertain to collected information, which includes:

• The right to review or request a copy of your/your child’s case information at any time.

• The right to refuse to answer any or all questions you consider sensitive; however, doing so may affect your eligibility for certain services with statutorily mandated information requirements.

• Your/your child’s information CANNOT be released to agencies or individuals outside of the OberlinKids Collaborative Partners without express consent and only when it is beneficial to do so as determined by your case manager and discussed with you.

OberlinKids Partners include:

Akron Children’s Hospital, Allen Memorial Art Museum, Applewood Centers, Inc., Bonner Center for Community-Engaged Learning, Teaching, and Research, Bright Beginnings/ODH DCY HMG, Catholic Charities Help Me Grow-Home Visiting, Child Care Resource Center, City of Oberlin, Common Ground-The Cindy Nord Center for Renewal, Connecting For Kids, Forget-Me-Not Center, Heart & Hand, LLC, Heartland Homestead, Kendal Early Learning Center,  Lorain County Community Action Agency, Lorain County Health & Dentistry, Lorain County Public Health, Lorain County Metroparks-Splashzone,  Mad Factory Theatre Company, Meadow Speech Therapy, Mental Health Addiction & Recovery Services Board of Lorain, MovementWorks Dance & Fitness, Neighborhood Alliance-Help Me Grow-Home Visiting, Oberlin Business Partnership, Oberlin City Schools, Oberlin Community Music School, Oberlin Community Services, Oberlin Early Childhood Center, OhioGuidestone, Oberlin Public Library,  Parent Representatives, Dr. Travis Wilson- Oberlin College Researcher, State Support Team Region 2, United Way of Greater Lorain County. 

Powered by the United Way of Greater Lorain County. Fiscal Agent and Lead Partner Kendal Northern Ohio

Regardless of authorization, certain disclosures may occur as a result of a court order, medical emergency, government audit, or to qualified personnel for program evaluation. Disclosure can also occur if you commit a crime against an agent working on behalf of OberlinKids Collaborative or is necessary to prevent serious, foreseeable, or imminent harm to yourself or other identified persons. Federal laws do not protect information about suspected child abuse or neglect from being reported under state law to state or local authorities. All disclosures will be recorded, unless prohibited by law enforcement order, to ensure information accountability and database integrity. Authorized staff who have received appropriate background checks, as well as proper user and confidentiality training, can access identified client information. Individual information that is entered into the database is stored in compliance with HIPAA regulations and other applicable federal, state, and local laws.

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.