# ASQ-3

Dear Parent/Caregiver:

Would you please take a few minutes to evaluate our questionnaires? We appreciate your participation in our program and hope that our services have been helpful to you.

Please circle the number that best expresses your opinion.

1.  Approximately how many minutes did it take you to fill out each questionnaire?  
    ______ minutes.

Did you consider this amount of time:  
very little time

Comments:

2.  Did the questionnaires alert you to skills your child has or activities your child could do that you were not sure about?  
very few                   very many  
    1    2    3    4

Comments:

3.  After filling out the questionnaires, did you have any new ideas about how to interact or play with your child?  
very few                   very many  
    1    2    3     4

Comments:

4. Were any items unclear or difficult to understand?  
very few                   very many  
    1  2  3  4

Comments:

5. Did you enjoy participating in this program?  
very little                   very much  
    1  2  3  4

Comments:

If you have any further comments about the questionnaires, please write them below.

*Ages & Stages Questionnaires®, Third Edition (ASQ-3™), Squires, Twombly, Bricker & Potter.* © 2009 Paul H. Brookes Publishing Co., Inc. All rights reserved.