ASQ-3 Questionnaire Cover Letter

Dear Parent/Caregiver:

Thank you for participating in our child screening/monitoring program. The enclosed questionnaire from the Ages & Stages Questionnaires®, Third Edition (ASQ-3™), is a screening tool that will provide a quick check of your child’s development. The information you supply will help reveal your child’s strengths, uncover any areas of concern, and determine if there are community resources or services that may be useful for your child or your family.

We’d like to ask you first to fill out the enclosed family information sheet, which helps us be sure we have the most up-to-date information possible. Then, please try the activities on the questionnaire with your child and record what you see and any concerns you’d like to share.

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.

Sincerely,

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