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

By clicking submit, you acknowledge that you have read the information provided about Ages and Stages Questionnaires (ASQ-3) and you will complete the questionnaires regarding your child's development and will return the completed questionnaires via the online questionnaires completion program. 

You also agree to receive information from SIU Head Start relative to the findings of this screening.

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.