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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As stated above the information you enter into this website is secure and cannot be seen or accessed by anyone other than the program employees who respond to the survey you submit. Information collected through the Ages and Stages Questionnaires will be entered into the Watch Me Grow data system to assist in analyzing information about how well the Watch Me Grow statewide screening system is working.  At no time will identifiable data be included in any report.

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