ASQ®-3/ ASQ®: SE-2 Parent/Guardian Consent Form – Print Version

Description and Purpose: The first 5 years of your child’s life are very important because this time sets the stage for success in school and later life. During infancy and early childhood, your child will gain many experiences and learn many skills. Screening to check in on communication, gross and fine motor skills, personal, problem-solving, and social-emotional development can show how your child is growing and changing over time, and whether your child is meeting the typical developmental and social-emotional milestones in playing, learning, speaking, behaving, moving and interacting in relationships.

You and your child have been invited to participate in a screening/ monitoring program by completing the Ages & Stages Questionnaires®, Third Edition (ASQ®-3) and/or the Ages & Stages Questionnaires®: Social-Emotional, Second Edition (ASQ®: SE-2), to help you keep track of your child's development. The organization offering this screening/ monitoring service to you will discuss your child’s screening results with you and provide any appropriate referrals and next steps.

Maintaining your child’s privacy is of utmost importance. The data from your child’s questionnaire(s) may be used for the following purposes:

1. The organization offering this screening/ monitoring services to you will input screening data into an online database as part of their screening/ monitoring program so that referrals and supports can be offered to your child as appropriate.
2. Statewide access to this screening/ monitoring program is made possible by a partnership between the Kansas State Department of Education, the Kansas Department of Health and Environment and local Kansas Infant-Toddler Services (Part C) programs providing early intervention services to infants and toddlers with disabilities and their families. Personal data may occasionally be transferred to the Part C program administrators managing this initiative in your community, designated Kansas State Department of Education employees, and authorized partners for further processing in accordance with the purposes for which the data was originally collected or for purposes to which you have subsequently consented. Where appropriate, before disclosing personal data, we contractually require the recipient to take adequate precautions to protect that data and maintain confidentiality.
3. To generate state- and regional-level aggregate summary-level reports that can be shared for purposes of scholarly research and analysis, including use in professional presentations and publications and to improve early childhood services throughout the State of Kansas.

Note: By signing below, you are agreeing to the consent or authorization information outlined on this page. Your consent can be revoked at any time by contacting the organization providing your child’s developmental screening.

I have read the information provided about the ASQ®-3/ASQ: SE®-2®, and I wish to have my child participate in the screening/ monitoring program. I will fill out questionnaires about my child’s development and will promptly return the completed questionnaires and I consent to this data being used as described in the information provided.

___________________________________________ Parent’s or guardian’s signature

___________________________________________ Date