Weeks Premature
(put "0" if not premature)

List others assisting with completion of the questionnaire

For ASQ:SE-2™ English

List others assisting with completion of the questionnaire

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 thrive in kindergarten.

Thank you for participating in our child screening and monitoring program. The Ages & Stages Questionnaires, Third Edition (ASQ-3), is a screening tool that will provide a quick check of your child’s development. The information you provide will be helpful in determining if there are community resources or services that may be useful for your child or your family.

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 the Developmental Screening Hub without your permission.

Once the questionnaire is completed, we will contact you if we have any questions and send you free book, a letter with the results, some fun activities to encourage his/her learning, and information on any community supports that may support/help you and your family.

Section 1.  The first section of the ASQ-3 looks at five developmental areas. Each area has six questions that go from easier to more difficult. Your child may be able to do some, but not all of the items. Read each question and mark:

• Yes your child is performing the skill
• Sometimes your child is performing the skill, or
• Not yet, which tells us your child is not yet performing the skill.

Following is a brief description of the five developmental areas:

• Communication: What your child understands and what they can say
• Gross motor: How your child uses their arms and legs, and how they coordinate their movements
• Fine motor: How your child uses their hands and fingers 
• Problem-solving: How your child plays with toys and solves problems
• Personal-social: How your child does with everyday activities and how they interact with their environment 

Section 2. The Overall section asks important questions about your child’s development and any concerns you may have about your child’s development. Answer questions yes or no, and if indicated, please explain your response.

Have fun completing this questionnaire with your child, and make sure he or she is rested, fed, and ready to play before you try the activities! If you have any questions or concerns, please contact me.

Sincerely, 

The Developmental Screening Hub

334 East Broadway, Louisville, KY 40202

[email protected]

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