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

List others assisting with completion of the questionnaire

For ASQ-3™ English

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I consent to the observation, screening and/or assessment for my child.  Screening and assessment may include health, vision, speech, language, motor, social, emotional and developmental skills according to the Early Learning Coalition of the Big Bend Region guidelines.  I understand that I will be infrormed of all results from these screenings and/or assessments. I also understand upon submission of this screening you are providing the Early Learning Coalition of the Big Bend to release screening and/or assessment information and results to my child's SR and/VPK provider, The Florida Diagnostic and Learning Resources System (FDLERS), Early Steps, Help Me Grow and any other diagnostic agency as necessary.

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