5 Odana Court
Madison, Wisconsin 53719

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Dear Parents and Caregivers:

The first five years of life can set the stage for success in school and later in life. It is important to ensure that every child is supported during this critical time of development. 4-C, in collaboration with United Way of Dane County, is happy to offer you a unique opportunity to learn more about your child’s development. 

The answers you provide in the Ages & Stages Questionnaire online screening will help to identify if your child is developing typically, their strengths, whether your child could use more practice in some areas of development, or whether your child could benefit from a more thorough developmental assessment.  Your personal information will be kept confidential; however, de-identified data may be collected and analyzed to create reports on children’s development within your county or region.  

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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 or heard the description of the questionnaire, and I wish to participate. I am willing to have the results shared with my child's physician and/or appropriate intervention programs. I also agree to receive information related to parenting and child development information by mail and/or e-mail.

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.