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

For ASQ:SE-2™ English

Participation in this program is voluntary and at no cost to you. Once your child's results have been reviewed by a Developmental Specialist and shared with you, the identifying information will be removed and your child's results will remain confidential. 

Your child’s non-identifying information will also be combined with that of others in this program and the data will be studied to help improve access to services for all children in the county.

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.