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

ASQ Consent Form

Dear Parent/Guardian,

The Massachusetts Department of Early Education and Care (EEC) and The Sandwich Partnership for Families

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.

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 acknowledge the Consent Form below. Thank you!

ASQ Online Family Consent Form

By completing the ASQ online, 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.

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.