Oak Park Pediatrics Ltd.1107 Chicago Ave.Oak Park, Illinois 60302
Child Date of BirthFormat: 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)
List others assisting with completion of the questionnaire
Oak Park Elementary School District 97 makes your use of this site possible through an arrangement with the Collaboration for Early Childhood Care & Education (Collaboration for Early Childhood). However, the information you enter into this website is confidential, secure and will not be seen or accessed by anyone in District 97. District 97 will not be reviewing your responses about your child.
The Collaboration for Early Childhood works to support all early childhood programs and services in Oak Park and River Forest to help them provide high quality programs and support your child’s development. Collaboration for Early Childhood may be providing guidance and support to Oak Park Pediatrics in their work with your child, by reviewing your child’s information and to assist staff’s efforts to support his or her development, including ways to meet any developmental needs.
As part of this effort the Collaboration has contracted with Chapin Hall at University of Chicago to analyze the aggregated data of the children participating in this program to help us understand how many children are being screened, what additional supports and services they are eligible to receive and whether they receive them. . Research is not conducted on individual children. Your child’s identifying information is removed from the data immediately upon transfer to Chapin Hall. The Collaboration and Chapin Hall maintain the strictest confidence with all of your child’s information and shall follow all laws and regulations relating to your and your child’s privacy rights.
By completing the ASQ – 3 and ASQ: SE-2 Questionnaires, you agree to:
1. Share your responses with Oak Park Pediatrics; and
2. Give permission to Oak Park Pediatrics to share your responses about your child, and any follow-up activities, with the Collaboration for Early Childhood.
Oak Park Pediatrics, the Collaboration for Early Childhood, Chapin Hall and District 97 will not share any information that identifies you, or your child with any other person, organization, agency or school without your further permission, or use your child’s information for commercial purposes. The permission you have granted in this form will end within 30 days after the last day of your child’s enrollment in Oak Park Pediatrics. I understand that my refusal to give permission to share my child’s information will NOT affect my child’s eligibility to participate in any program, but it may make it more difficult for Oak Park Pediatrics to provide coordinated services to your child.
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.
