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

For ASQ:SE-2™ English

Dear Parent/Guardian:
The Massachusetts Department of Early Education and Care (EEC) and the Medford Family Network
(MFN) invite you to complete the Ages & Stages Questionnaires® (ASQ®) with your child. The ASQ® is a
developmental screening tool that provides you with a quick check of your child's development. It is
easy to use and typically takes about ten minutes to complete.
The ASQ® provides a snapshot of your child's development and it focuses on what your child can do. It
celebrates your child's strengths, highlights developmental milestones, and identifies any areas that may
need more support. Regular screenings allow you to learn about your child's development and to
address any questions or concerns you may have about what typical development looks like. It allows
you to participate in the decision-making opportunities related to your child's early education and care
programming, and it provides your program with invaluable knowledge about your child. Additionally,
you may receive an activities sheet filled with ideas on how to extend the learning at home.
Two TYPES OF ASQ® DEVELOPMENTAL SCREENING TOOLS AVAILABLE:
You have an opportunity to complete one or both of the following ASQ® developmental screening tools:
1. Ages & Stages Questionnaires® - Third Edition (ASQ® DEV-3) addresses communication, gross
motor, fine motor, problem solving, and personal-social skills.
2. Ages & Stages Questionnaires® : Social-Emotional - Second Edition (ASQ® :SE-2): addresses
self-regulation, compliance, communication, adaptive behaviors, autonomy, affect, and
interaction with people.
WHY WE COLLECT ASQ® DATA:
The MFN and EEC collect ASQ® screening data to identify trends and patterns in the early education and
care settings in order to better support the programs with resources and professional development
opportunities. EEC is only analyzing the combined scores of all the screening results. The specific names
of children are not included in the analysis.
ASQ® results are confidential. Both MFN and EEC follow the Massachusetts confidentiality laws to
ensure that your and your child's personally identifiable information is protected.
EEC signed a data-sharing agreement with United Way to jointly develop a data platform to analyze the
combined data. The data-sharing agreement ensures that all individuals accessing the data will maintain
confidentiality and ensure your and your child's privacy.
If you do not wish to have your child's information entered into the online database, you may decline
this option. Your child may be screened using the ASQ® paper version of the questionnaire, and no
information will be shared.
Last updated: June 5, 2020

Please read the text below and click on the "submit button" if you choose to proceed with the Ages &
Stages Questionnaires® (ASQ®) screening on line via the Family Access Link provided to you by the
Medford Family Network

I acknowledge that I have read the information provided by the Department of Early Education and Care
(EEC) about the ASQ® screening process and choose the following option:

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.