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

It is the goal of Head Start to provide services to children that will enhance their growth and development. These screening tools assist in planning for your child’s health and/or educational needs, and are a requirement of Federal Head Start Performance Standards.

By completing this screening, you have agreed to the terms stated in our consent form and give Albina Head Start and their representative’s permission to obtain and review this developmental 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.