### SAMPLE ASQ-3 SCREENING RESULTS, BY CHILD REPORT

| Child Name           | Provider      | Child ID | Child DOB    | Interval (mo.) | Questionnaire Type | Screening Date | Screening Completed By    | Communication Score | Communication Cutoff | Communication Results | Gross Motor Score | Gross Motor Cutoff | Gross Motor Results | Fine Motor Score | Fine Motor Cutoff | Fine Motor Results | Problem Solving Score | Problem Solving Cutoff | Problem Solving Results | Personal-Social Score | Personal-Social Cutoff | Personal-Social Results | Overall Concern | Overall No Concern |
|----------------------|---------------|----------|--------------|----------------|--------------------|----------------|--------------------------|---------------------|----------------------|----------------------|-------------------|---------------------|---------------------|------------------|-------------------|-------------------|-----------------------|-----------------------|-----------------------|-----------------------|----------------------|--------------------------|------------------|-----------------|
| Black, Fiona         | Perkins, Amy  | 2832938  | 11/10/2019   | 48 Month       | ASQ-3 English      | 9/13/2023      | Black, Pat (Mother)      | 60                  | 30.72                | Above                | 40                | 32.78               | Monitoring          | 50               | 15.81             | Above             | 20                    | 31.3                  | Below                 | 60                    | 26.6                | Above                    | 0                | 10              |
| Bollinger, Kelley    | Perkins, Amy  | 2746922  | 1/2/2019     | 54 Month       | ASQ-3 English      | 9/21/2023      | Bollinger, Eric (Father) | 50                  | 31.85                | Above                | 35                | 35.18               | Below              | 50               | 17.32             | Above             | 60                    | 28.12                 | Above                 | 50                    | 32.33               | Above                    | 1                | 9               |
| Gonzalez, Chris      | Perkins, Amy  | 2746920  | 12/3/2018    | 60 Month       | ASQ-3 English      | 10/1/2023      | Gonzalez, Paul (Father)  | 45                  | 33.19                | Above                | 60                | 31.28               | Above              | 30               | 26.54             | Monitoring         | 40                    | 29.99                 | Monitoring            | 55                    | 39.07               | Above                    | 0                | 10              |
| Truckenbrodt, Daniel | Perkins, Amy  | 3231341  | 2/1/2020     | 42 Month       | ASQ-3 Spanish      | 9/15/2023      | Truckenbrodt, Daniel (Father) | 60              | 27.06                | Above                | 60                | 36.27               | Above              | 45               | 19.82             | Above             | 60                    | 28.11                 | Above                 | 35                    | 31.12               | Monitoring            | 1                | 9               |