Hampton Roads Developmental Screening Initiative
United Way of South Hampton Roads
2515 Walmer Ave
Norfolk, Virginia 23513
www.unitedwayshr.org

WELCOME! Welcome to the United Way of South Hampton Roads' Family Access for the Ages & Stages Questionaire.

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Because your child's first 5 years of life are so important, we want to help you provide the best start for your child. You've been invited to participate in the Ages & Stages Questionnaires, Third Edition (ASQ-3), to help you keep track of your child's development. The questionnaire may be provided every 2-, 4- or 6-month period. You will be asked to answer questions about some things your child can and cannot do. The questionnaire includes questions about your child's communication, gross motor, fine motor, problem solving, and personal social skills.

Please enter your child's birth date and the number of weeks he or she was born premature below to start the screening. Please note that the information you enter into this website is secure and cannot be seen or accessed by anyone other than the program employees who have invited you to participate in this screening.

We look forward to your participation in ASQ-3!



(put "0" if not premature)



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.