Weeks Premature
(put "0" if not premature)

List others assisting with completion of the questionnaire

For ASQ:SE-2™ English

List others assisting with completion of the questionnaire

I have read the provided information about the Ages & Stages Questionnaire (ASQ-3), 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 the Family Access online completion questionnaire system.

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.