Oak Park Pediatrics Ltd.
1107 Chicago Ave.
Oak Park, Illinois 60302

Welcome to the Ages and Stages Questionnaire online.  All families enrolled in Oak Park Pediatrics are asked to complete this questionnaire as part of our program and to help us support your child’s growth and development.

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: Social-Emotional, Second Edition (ASQ:SE-2) to help you keep track of your child's social and emotional development. The questionnaire may be provided for use at least two times per year from 1 month to 72 months of age. You will be asked to answer questions about some of your child's behaviors. The questionnaire includes questions about your child's ability to calm down, take direction and follow rules, communicate, perform daily activities (e.g., eating, sleeping), act independently, demonstrate feelings, and interact with others.

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:SE-2!



(put "0" if not premature)

Oak Park Elementary School District 97 makes your use of this site possible through an arrangement with the Collaboration for Early Childhood Care & Education (Collaboration for Early Childhood).  However, the information you enter into this website is confidential, secure and will not be seen or accessed by anyone in District 97.  District 97 will not be reviewing your responses about your child.

The Collaboration for Early Childhood works to support all early childhood programs and services in Oak Park and River Forest to help them provide high quality programs and support your child’s development.  Collaboration for Early Childhood may be providing guidance and support to Oak Park Pediatrics in their work with your child, by reviewing your child’s information and to assist staff’s efforts to support his or her development, including ways to meet any developmental needs.  

As part of this effort the Collaboration has contracted with Chapin Hall at University of Chicago to analyze the aggregated data of the children participating in this program to help us understand how many children are being screened, what additional supports and services they are eligible to receive and whether they receive them. .  Research is not conducted on individual children. Your child’s identifying information is removed from the data immediately upon transfer to Chapin Hall.  The Collaboration and Chapin Hall maintain 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. 

By completing the ASQ – 3 and ASQ: SE-2 Questionnaires, you agree to:

1. Share your responses with Oak Park Pediatrics; and

2. Give permission to Oak Park Pediatrics to share your responses about your child, and any follow-up activities, with the Collaboration for Early Childhood.

 

Oak Park Pediatrics, the Collaboration for Early Childhood, Chapin Hall and District 97 will not share any information that identifies you, or your child with any other person, organization, agency or school without your further permission, or use your child’s information for commercial purposes. The permission you have granted in this form will end within 30 days after the last day of your child’s enrollment in Oak Park Pediatrics.  I understand that my refusal to give permission to share my child’s information will NOT affect my child’s eligibility to participate in any program, but it may make it more difficult for Oak Park Pediatrics to provide coordinated services to your child.

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.