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:SE-2™ English

For ASQ-3™ English

The Rock Island County All Our Kids Early Childhood Network collaborates with many early childhood programs and services in the community to help them provide high quality programs for children and families, and support your child's development and learning. The AOK Network Coordinator will review your child's information in an effort to support his or her development, including ways to meet any developmental needs. The information you enter into this website is confidential, secure and will not be seen or accessed by anyone other than the Local AOK Network Coordinator without your further permission. The AOK Network will not share any information that identifies you, or your child, with any other person, organization, agency or school without your further permission.

As part of this effort, the AOK Network may also analyze the aggregated data of the children participating in this program to help us understand how many children are being screened, the overall developmental needs of children in our community, and what additional supports and services they are eligible to receive and what services are still needed. Your child's identifying information is removed from the data immediately upon transfer. The AOK Network maintains the strictest confidence with all of your child's information, and shall follow all laws and regulations relating to your and your child's privacy rights.

I have read the provided information about the Ages & Stages Questionnaires, and I wish to have my child participate in the online screening program. I will fill out the questionnaire about my child's development and promptly submit the completed questionnaire through this Family Access online questionnaire completion system. By completing the Questionnaires, I agree to:

1. Share responses about my child with the AOK Network Coordinator

2. Give permission to the AOK Network to aggregate my responses about my child, and any follow-up activities and share this information with community stakeholders.

The permission you have granted by submitting the completed questionnaires will end within one year from the date of the last online screening completed through this program, unless otherwise revoked in writing to the Local AOK Network Coordinator.

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.