Cape Cod Children's Place

10 Ballwic Road North Eastham O2651

[email protected]

508-240-3310

Welcome to our ASQ Online screening program!

As your children's first and most important teacher, we appreciate your interest in learning more about your child's development. Do not hesitate to reach out to our Child Development Speciliasts if you have questions or need help with the questionaire. We have several Speciliasts throughout the Cape. Our main number is 508-24-3310. Have fun with your child!

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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, Third Edition (ASQ-3), to help you keep track of your child's development. The questionnaire may be provided every 2-, 4- or 6-month period. You will be asked to answer questions about some things your child can and cannot do. The questionnaire includes questions about your child's communication, gross motor, fine motor, problem solving, and personal social skills.

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-3!



(put "0" if not premature)



Cape Cod Children's Place and EEC collect ASQ® screening data to identify trends and patterns in the early education and care settings in order to better support the programs with resources and professional development opportunities.  EEC is only analyzing the combined scores of all the screening results.  The specific names of children are not included in the analysis. ASQ® results are confidential.  Both Cape Cod Children's Place and EEC follow the Massachusetts confidentiality laws to ensure that your and your child’s personally identifiable information is protected. EEC signed a data-sharing agreement with United Way to jointly develop a data platform to analyze the combined data.  The data-sharing agreement ensures that all individuals accessing the data will maintain confidentiality and ensure your and your child’s privacy. If you do not wish to have your child’s information entered into the online database, you may decline this option.  Your child may be screened using the ASQ® paper version of the questionnaire, and no information will be shared.

Paper Consent Form

This form requests your permission to participate in the developmental screening process with your child; to enter your child's screening data into an online database; and to share your child’s de-identified screening data with the Department of Early Education and Care (EEC) and any of its designated agents, assigns, partners, contractors, or subcontractors (in this case, United Way).   

Initial the box(es) of the ASQ® that you wish to complete.  

I acknowledge that I have read the information provided by Cape Cod Children's Place and EEC about the ASQ® screening process, and I choose the following option(s):

 

ASQ® Participation Options 

Initial for

ASQ®-3

Initial for

ASQ®: SE-2

I agree to complete the ASQ®, and Cape Cod Children's Place may enter my child’s information into the online database to be shared with EEC for the data summary report.*

   

I agree to complete the ASQ® andCape Cod Children's Place may not enter my child’s information into the online database and may not be shared with EEC for the data summary report.* 

         

I decline to participate in the screening process.  

   



_________________________________

Name of Child



___________________________________________________________

Signature of Parent or GuardianDate



_________________________________

Name of Parent or Guardian




* The data summary reports will only compile combined scores from all children and will not include the specific names of children.

ONLINE CONSENT FORM 

Please read the text below and click on the “submit button” if you choose to proceed with the Ages & Stages Questionnaires® (ASQ®) screening online via the Family Access Link provided to you by Cape Cod Children's Place.

I acknowledge that I have read the information provided by the Department of Early Education and Care (EEC) about the ASQ® screening process and choose the following option:






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.

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