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

Welcome to our ASQ Online screening program!

View description Hide description

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)

ASQ Consent Form

 

Dear Parent/Guardian,

 

The Massachusetts Department of Early Education and Care (EEC) and the Chelsea / Revere Family Network

 

Program Name

would like to invite you to engage in developmental screening with your child using the Ages and Stages Questionnaire (ASQ). Developmental screening provides families the opportunity to share and learn about their child’s development, to celebrate their growth, and to address any questions or concerns they may have about what “typical” development looks like.

 

The ASQ is designed to be filled out by families. It is user-friendly, and should only take about 10 minutes to complete. It can be filled out on paper or online. Your child’s early education and care program can also do it with you in person, and provide you with the results.

 

The Consent Form below requests your permission for you to engage in developmental screening with your child, and to have your child's screening data entered into an online database. Using that data, your child’s early education and care program can look at your child’s development, and can connect you with community resources to support your child, if needed.

 

The Consent Form also requests your permission to share the data with EEC. The combined data from developmental screening across the Commonwealth helps inform the ways EEC supports educators and families to respond to children’s needs through training and resources. Please note that EEC will combine the data of many children and will not be able to identify specific individual children. Screening data will be confidential to ensure your privacy. If you do not wish to have information entered online and shared with EEC, you may decline this option and your child may still be screened using the ASQ paper questionnaire.

 

If you choose to participate in any of these developmental screening activities, please complete the Consent Form below. Thank you!

 

 

 

 

 

 

 

 

 

 

 

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.