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

List others assisting with completion of the questionnaire

For ASQ:SE-2™ English

List others assisting with completion of the questionnaire

I am the parent or legal guardian of this child with authority to make healthcare decisions for my child. By clicking submit, I agree to allow data entered through this electronic form to be stored in a secure database for my provider to review.

If I choose not to submit this and share my child’s screening data as stated above, I may request a paper screening option from my child’s provider.

I understand that signing this authorization is voluntary. I understand this authorization will expire upon my child's 18th birthday.

I understand that I may revoke this authorization at any time and the revocation does not apply to any action that has taken place prior to the date I revoke this authorization.

To revoke this authorization, I must make a request in writing and send it to: [email protected].

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.