ASQ Online

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Metro United Way
502-292-6159
kimberly.Broecker@MetroUnitedWay.org
334 East Broadway
Louisville, Kentucky 40204
www.MetroUnitedWay.org

Welcome to ASQ Online! Your interest in the healthy development of your child is the first and most important step to ensure that your child is safe, healthy, nurtured, and prepared to succeed in kindergarten.

First of all, let me assure you that none of your or your child’s personal information will be shared with anyone. We will combine the results of all of the children who conduct the screenings to look at the community overall, but no information about your family will be made available to anyone besides Metro United Way.

Once the questionnaire is completed, we will score the screening and send you a letter with the results, some easy things you can do to help your child develop on time, and information on any services your child might need.

You will also receive a FREE book for your child for completing both the questionnaires.

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Because your child's first 5 years of life are so important, we want to help you provide the best start for your child. You've been invited to participate in the Ages & Stages Questionnaires: Social-Emotional, Second Edition (ASQ:SE-2) to help you keep track of your child's social and emotional development. The questionnaire may be provided for use at 2, 6, 12, 18, 24, 30, 36, 48, or 60 months of age. You will be asked to answer questions about some of your child's behaviors. The questionnaire includes questions about your child's ability to calm down, take direction and follow rules, communicate, perform daily activities (e.g., eating, sleeping), act independently, demonstrate feelings, and interact with others.

Please enter your child's birth date and the number of weeks he or she was born premature below to start the screening. Please note that the information you enter into this website is secure and cannot be seen or accessed by anyone other than the program employees who have invited you to participate in this screening.

We look forward to your participation in ASQ:SE-2!

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)

Screening Date I am screening my child today (2022-05-28) I screened my child and am entering in the responses to a previous screening

By submitting this form, I attest that I am the above’s legal guardian and I agree to enroll my child in the Ages & Stages Questionnaires monitoring program and into My Big Little Adventure’s weekly newsletter. For more information on My Big Little Adventure..

By providing my child's health care provider information, I agree to allow Metro United Way (MUW) to share information about my child and my child's ASQ results with my health care provider. You may opt out at any time by contacting kimberly.broecker@metrounitedway.org

To better communicate and facilitate your participation in the program, If you are involved or enrolled with Play Cousins Collective, or their advocates, Metro United Way will be providing Play Cousins Collective with limited access to of your family/child’s information.

Play Cousins will have access to:

General contact information.
Interactions between the developmental screening coordinators and your family.
Your participation rates and if you are due for a gift card.
Any needed services, and any information regarding referrals made by Metro United Way and/or connections made by the family.

You may opt out at any time by contacting kimberly.broecker@metrounitedway.org.

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.