Caesar Rodney Early Intervention Program
302-697-4145
Linda.davis@cr.k12.de.us
3874 Upper King Rd.
Dover, Delaware 19904



(put "0" if not premature)

For ASQ-3™ English

For ASQ:SE-2™ English

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 understand aggregated information with be shared with the Delaware Office of Early Learningand the Delaware Department of Public Health to determine developmental trends for making budget and resource allocations. Screening results will be shared with your child's child care and District of Residence.

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