Brookes ASQ | ASQ:SE2 - ASQ-3 English

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Welcome Families of Ka’lulani Child Care ! You are about to access our ASQ:SE2 Online screening program!

Child Date of Birth

Month Day Year

Weeks Premature
(put "0" if not premature)

For ASQ:SE-2™ English

Screening Date

I am screening my child today (2025-05-12) I screened my child and am entering in the responses to a previous screening

List others assisting with completion of the questionnaire

For ASQ-3™ English

Screening Date I am screening my child today (2025-05-12) I screened my child and am entering in the responses to a previous screening

List others assisting with completion of the questionnaire

Consent

*I have read the provided information about the MtFFC screenings. I wish to have my child participate in the screening and monitoring program.

*I have read, understand, and agree to the online consent. Please complete the consent here if you haven’t already: ESEP consent with Ka'iulani

*I have received a copy of the HIPAA statement: ESEP HIPAA

*I agree to be contacted by an Easterseals specialist, who will share the results with me and also give me activities and/or connect you to community resources in line with my child’s individual needs.

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.