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

For ASQ:SE-2™ English

If you would like to participate in this program, it is voluntary and at no cost to you. A Family Engagement Specialist will share your child's results with you only. Results will remain confidential and will not be shared without a caregiver's consent.

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