A To Z Building Blocks - CC
801-763-0722
atozbuildingblocks@gmail.com
195 N 100 E
American Fork, Utah 84003

ASQ-3

Welcome to the Department of Health and Human Services, Ages and Stages Questionnaire® (ASQ) program; in partnership with A to Z Building Blocks!

Thank you for taking the time to complete this questionnaire.  A to Z Building Blocks is a place where children are loved, taught and given opportunities to grow.  Assessing children is a great tool to know where we can better serve our families!

We feel that the early years of a child are very critical to a child's life.  By participating in this assessment tool we will be able to work together to make sure that your child is developing the way he/she is supposed to.

Completing this questionnaire gives A to Z Building Blocks permission to conduct assessments with your child too.  A to Z Building Blocks will make the parent fully aware of any concerns and provide additional resources to seek further help.  A to Z Building Blocks will not diagnose any special need and will only refer you to outside sources.

This developmental screening opportunity is provided by the Department of Health and Human Services (DHHS). DHHS partners with early care and education providers, to ensure all families with young children have access to developmental screening.

Use of Data

Early childhood programs rely on data to inform decisions about effective early childhood policy and services. Data helps DHHS understand which practices work best and provide evidence to advocate for additional funding to best support Utah families and young children.

Participation in ASQ online is optional. A-Z Building Blocks partners with DHHS to collect basic information about your family and the services provided. DHHS is committed to protecting the personal data it maintains on behalf of its citizens.  The DHHS Privacy Policy and Consent to Use of Data is available here. 

To get started with the ASQ Online Questionnaire, please enter your child's birth date and the number of weeks he or she was born premature below to start the screening. 

Complete the questionnaire by doing the activities with the child.  If you have already seen the child do the activity you may answer the question however, if you have never observed the activity you must do it with the child in order to provide an accurate answer.

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)

Screening Date I am screening my child today (2023-06-04) I screened my child and am entering in the responses to a previous screening

List others assisting with completion of the questionnaire

I am the parent or legal guardian of this child with authority to make healthcare decisions for my child. By clicking submit, I agree to allow data entered through this electronic form to be stored in a secure database for my provider to review.

If I choose not to submit this and share my child’s screening data as stated above, I may request a paper screening option from my child’s provider.

I understand that signing this authorization is voluntary. I understand this authorization will expire upon my child's 18th birthday.

I understand that I may revoke this authorization at any time and the revocation does not apply to any action that has taken place prior to the date I revoke this authorization.

To revoke this authorization, I must make a request in writing and send it to: ecids@utah.gov.

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.