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

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For ASQ:SE-2™ English

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Your participation in completing this ASQ-3 screening indicates your agreement to allow Community Coordinated Care for Children, Inc. (4C) and the Early Learning Coalitions of Orange and Osceola Counties to share demographic, screening and referral activities.

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