## Dear Parent/Caregiver:

Welcome to our screening and monitoring program. Because your child’s first 5 years of life are so important, we want to help you provide the best start for your child. As part of this service, we provide the Ages & Stages Questionnaires, Third Edition (ASQ-3), to help you keep track of your child’s development. A questionnaire will be provided every 2-, 4-, or 6-month period. You will be asked to answer questions about some things your child can and cannot do. The questionnaire includes questions about your child’s communication, gross motor, fine motor, problem solving, and personal-social skills.

If the questionnaire shows that your child is developing without concerns, we will provide some activities designed for use with ASQ-3 to encourage your child’s development and will provide the next questionnaire at the appropriate time.

If the questionnaire shows some possible concerns, we will contact you about getting a more involved assessment for your child. Information will only be shared with other agencies with your written consent.

We look forward to your participation in our program!

## Section 1: The first section of ASQ-3 includes five developmental areas. Each area has six questions that go from easier to more difficult skills. Your child may be able to do some but not all of the items. Read each question and mark

- **Yes** if your child is performing the skill
- **Sometimes** if your child is performing the skill but doesn’t yet do it consistently
- **Not yet** if your child does not perform the skill yet

Here is a brief description of the five developmental areas screened with ASQ-3:

- **Communication:** Your child’s language skills, both what your child understands and what he or she can say
- **Gross motor:** How your child uses his or her arms and legs and other large muscles for sitting, crawling, walking, running, and other activities
- **Fine motor:** Your child’s hand and finger movement and coordination
- **Problem solving:** How your child plays with toys and solves problems
- **Personal-social:** Your child’s self-help skills and interactions with others

## Section 2: The Overall section asks important questions about your child’s development and any concerns you may have about your child’s development. Answer questions by marking yes or no, and if indicated, please explain your response.

Have fun completing this questionnaire with your child, and make sure he or she is rested, fed, and ready to play before you try the activities! Please be sure to send back the questionnaire within 2 weeks. If you have any questions or concerns, please contact me.