CAPIC/Chelsea-Revere Family Network
617-887-0076
jvelez@capicinc.org
67 Crescent Ave
Chelsea, Massachusetts 02150

Welcome to our ASQ Online screening program!

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Because your child's first 5 years of life are so important, we want to help you provide the best start for your child. You've been invited to participate in the Ages & Stages Questionnaires, Third Edition (ASQ-3), to help you keep track of your child's development. The questionnaire may be provided every 2-, 4- or 6-month period. You will be asked to answer questions about some things your child can and cannot do. The questionnaire includes questions about your child's communication, gross motor, fine motor, problem solving, and personal social skills.

Please enter your child's birth date and the number of weeks he or she was born premature below to start the screening. Please note that the information you enter into this website is secure and cannot be seen or accessed by anyone other than the program employees who have invited you to participate in this screening.

We look forward to your participation in ASQ-3!



(put "0" if not premature)

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.

 

 

ASQ Online Family Consent Form

 

 

 

 Please read the text below and check the box to indicate whether you and your child agree to participate in the ASQ screening:

 

 

 

¨ By checking this box, I acknowledge that I have read the information provided by the Department of Early Education and Care (EEC) about the ASQ screening tool and:

 

 

 

·                       I agree to engage in developmental screening with ASQ to learn more about their developmental progress, and

 

·                       I agree to have my child's screening information entered into the ASQ online database, and

 

·                       I agree to have my child’s screening information shared with EEC for the purposes of state-wide data collection that looks only at totaled data to determine screening trends, future trainings for early childhood professionals, and policies.

 

 

 

¨ By checking this box, I acknowledge that I have read the information provided by the Department of Early Education and Care (EEC) about the ASQ screening tool and:

 

 

 

·                       I agree to engage in developmental screening with ASQ to learn more about their developmental progress, but

 

·                       I do not agree to have my child's screening information entered into the ASQ online database, and

 

·                       I do not agree to have my child’s screening information shared with EEC

 

 

 

 

 

¨  By checking this box, I acknowledge that I have read the information provided by EEC about the ASQ screening tool, and I decline to have my child screened with the ASQ.

 

 

 

 

 

 

 

_________________________________                                              __________________________

 

Name of Parent or Guardian                                                                       Date

 

 

 

_________________________________

 

Signature of Parent or Guardian               

 

 

 

 

 

 

 

 

 

 

 

 

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.