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

IMPORTANT...PLEASE READ BEFORE CONTINUING

CONSENT FORM

The first 5 years of life are very important for your child(ren) because this time sets the stage for success in school and later life. During infancy and early childhood, you child(ren) will gain many experiences and learn many skills. It is important to ensure that each child’s development proceeds well during this period.

Please read the text below to indicate whether you will participate in the screening/monitoring program.

I have read the provided information about the Ages & Stages Questionnaires (ASQ-3), and I wish to have my child(ren) participate in the monitoring program. I will fill out the questionnaires about my child’s development and promptly return the completed questionnaires through the online questionnaire completion system.

BY CLICKING ON "SUBMIT", YOU ARE CONSENTING TO HAVING YOUR CHILD(REN) PARTICIPATE IN THE MONITORING PROGRAM.

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.