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

List others assisting with completion of the questionnaire

For ASQ:SE-2™ English

List others assisting with completion of the questionnaire

As part of consenting to do the ASQ screenings, I understand that screening information entered online will be shared with the Delaware Department of Education, Office of Early Learning,  the Delaware Department of Public Health and Delaware Health and Social Services  to determine overall developmental trends that will help with budget and resource decisions. Screening results will also be shared with your childcare provider, because they must keep track of completed developmental screenings (required by Delaware STARs) and your district of residence if there is a concern.

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