ASQ Online

Early Childhood Council of Hillsborough County
4210 West Bay Villa Avenue
Tampa, Florida 33611
http://ecctampabay.org/help-me-grow/

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:SE-2™ English

Screening Date I am screening my child today (2020-07-04) I screened my child and am entering in the responses to a previous screening

For ASQ-3™ English

Screening Date I am screening my child today (2020-07-04) I screened my child and am entering in the responses to a previous screening

I have read the provided information about the Ages & Stages questionnaires, and I wish to have my child participate in the online screening program. I will fill out the questionnaire about my child's development and promptly submit the completed questionnaire through this Family Access online questionnaire completion system. I agree to allow Help Me Grow Florida to enter this data into a secure database in order to follow-up with me on the results of this screening and provide me with other relevant sources.

By completing this screening, you are authorizing the information you provide to be released to/from Help Me Grow partners.

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.