Weeks Premature
(put "0" if not premature)

List others assisting with completion of the questionnaire

For ASQ:SE-2™ English

List others assisting with completion of the questionnaire

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.

OberlinKids Confidentiality Statement

Your privacy matters to us. Information collected by OberlinKids helps us better understand and support your child and family.  Non-identifying information may be used for overall program review and data reporting. Personal information is kept confidential and will never be shared outside of the OberlinKids Collaborative without your knowledge and consent, including when connecting your family with requested services or resources.

OberlinKids Community Partners are bound by Collaborative confidentiality requirements designed to protect the privacy of information stored in Collaborative databases or discussed as part of service coordination and referrals. This allows OberlinKids to:

• Improve services and provide individualized support based on each family’s needs.

• Identify appropriate resources while reducing duplicate data collection for families.

• Use non-identifying information to track program outcomes, identify unmet needs, allocate resources, plan services, report the Collaborative’s progress to the community, and support funding opportunities.

You have the right to:

• Review or request a copy of your or your child’s information at any time.

• Refuse to answer questions you consider sensitive; however, some information may be required to determine eligibility for specific services.

• Have your or your child’s identifying information kept confidential. Identifying information will not be released to individuals or organizations outside of the OberlinKids Collaborative without your knowledge and consent, except when disclosure is required or permitted by law as described below.

A current list of OberlinKids Community Partners is available at oberlinkids.org/partners. All participating Community Partners have agreed to OberlinKids confidentiality requirements and have a current Memorandum of Understanding on file with OberlinKids.

Certain information may be disclosed without your authorization when required or permitted by law, including in response to a court order, medical emergency, government audit, suspected child abuse or neglect, or when necessary to prevent serious, foreseeable, or imminent harm. Access to identified information is limited to authorized individuals with appropriate access and confidentiality training.

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.