# What Is ASQ-3™? ASQ-3™ is a set of questionnaires about children’s development. It has been used for more than 20 years to make sure children are developing well. A screening provides a quick look at how children are doing in important areas, such as communication, physical ability, social skills, and problem-solving skills. ASQ-3 can help identify your child’s strengths as well as any areas where your child may need support. As a parent or caregiver, you are the best source of information about your child. That’s why ASQ-3 questionnaires are designed to be filled out by you. You will only need 10–15 minutes. It’s that quick and easy. Here’s how ASQ-3 works: - You will answer each question “yes,” “sometimes,” or “not yet,” based on what your child is able to do now. Your answers help show your child’s strengths and areas where he or she may need practice. - To answer each question, you can try fun and simple activities with your child. These activities encourage your child to play, move around, and practice day-to-day skills. - After you complete the questionnaire, a professional will share the results with you. If your child is developing without concerns, there is nothing more you will need to do. You may try the next ASQ-3 age level as your child grows and learns new skills. There are 21 questionnaires that you can use with children from 1 month to 5½ years old. If your child has trouble with some skills, your program will help you with next steps. Finding delays or problems as early as possible supports young children’s healthy development. You are an active partner in your child’s learning and development. By completing ASQ-3 questionnaires, you are making sure your child is off to the best possible start! ### To find out more, please talk to your health care or education professional, or visit www.agesandstages.com. ## 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! ## Consent Form The first 5 years of life are very important for your child 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. It is important to ensure that each child’s development proceeds well during this period. Please read the text below and mark the desired space to indicate whether you will participate in the screening/monitoring program. I have read the information provided about the Ages & Stages Questionnaires®, Third Edition (ASQ-3™), 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. I do not wish to participate in the screening/monitoring program. I have read the provided information about the Ages & Stages Questionnaires®, Third Edition (ASQ-3™), and understand the purpose of this program. - Parent or guardian’s signature - Date - Child's Name:_____ - Child's date of birth:_____ - If child was born 3 or more weeks prematurely, # of weeks premature:__________________ - Child's primary physician:____ ## Demographic Information Sheet - Today's date: ____ - Child's name (first/middle/last): ____ - Child's date of birth (MM/DD/YYYY): ____/____/____ - If child was born premature, # of weeks premature: _________________________________ - Child’s gender: Male O O Female - Child's race/ethnicity: ____ - Child's birth weight (pounds/ounces): ____ - Parent/primary caregiver’s name (first/middle/last): __________________________________ - Relationship to child: ____. - Street address: ____ - City: ____ - State/province: ____ ZIP/postal code: ____ - Home telephone: ____ Work telephone: ____ - Cell/other telephone: ____ - Child's primary language: ____ ## ASQ-3 - Child's primary care physician: ____ - Clinic/location/practice name: ____ - Clinic/practice mailing address: ____ - Telephone: ____ - Fax: ____ - Please list any medical conditions that your child has: ____ - Please list any other agencies that are involved with your child/family: ## Program Information - Child ID #: ____ - Date of admission to program: ____ - Child’s adjusted age in months and days (if applicable): ______________________________ - Program ID #: ____ - Program Name: ____ ## 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.