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

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For ASQ:SE-2™ English

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I am completing this Developmental Screening online through the University of Arizona Cooperative Extension, Pinal County for the purpose of evaluating my child's developmental progress. I am aware that after the screening is processed, someone from the developmental screening team will contact me, with the results. I understand the results of the screening may be shared with my child's AHCCCS plan, doctor, First Things First, County, and its partners. I understand the screenings performed are not a medical diagnosis, but only a tool to help keep track of my child’s development as well as possibly uncover early developmental delays which can be followed up with the appropriate resource agency depending on the age of the child. I am aware that I am responsible for following up if a referral for more evaluation is recommended.

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