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

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Participation in this program is voluntary and at no cost to you.  Once your child’s results have been reviewed by your child’s teacher, they will be shared with you, along with resources and activities that will increase your child’s growth and development.

Following submission of your screening, your child’s identifying information will be removed and your child’s statistical results will be combined with that of others in this program to increase state and national understanding of child development. This data will be studied to help improve access to services for all children and early intervention supports for children across Wayne County.

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.