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

We are committed to your privacy and the privacy of your child. Any information you submit in the ASQ online system can only be viewed by our staff who have authorized access to your account. All information collected will be treated as confidential and will only be shared with your written consent.

The State of Alaska EI/ILP has provided funding for this project to provide access to developmental screening for all families. The State EI/ILP staff will be tracking the number of children who are screened but will not be able to view any identifying information. All information collected is procted under the Family Education Rights and Privacy Act (FERPA) and Health Insurance Protability and Accountability Act (HIPPA).

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.