Child Monitoring Sheet

Child's name: ____

Date of birth: _____________________

Child gender:

• Male
• Female

Instructions: 2 screening results over time. Write the date the ASQ:SE-2 was administered at the top of each column. You may use this form to track a child’s ASQ:SE-

1. Mark the bubble that corresponds with the ASQ:SE-2 result (refer to the completed ASQ:SE-2 Information Summary). If a score is below the monitoring zone, mark the bubble for “Well Below.” If a score is within the monitoring zone, mark “Monitor.” If a score is above the cutoff, mark “Above.”
2. Indicate the total number of scored items that the caregiver marked as a Concern.
3. Mark “Yes” or “No” to indicate whether there were items of Concern in the Overall section and whether there was a parent conference.
4. Optional: Record any follow-up action/notes.
5. Optional: Record the average item score by dividing the ASQ:SE-2 total score by the number of answered scored items.

| | ASQ:SE-22 month Date given | ASQ:SE-26 month Date given | ASQ:SE-212 month Date given | ASQ:SE-218 month Date given | ASQ:SE-224 month Date given | ASQ:SE-230 month Date given | ASQ:SE-236 month Date given | ASQ:SE-248 month Date given | ASQ:SE-260 month Date given | | --- | --- | --- | --- | --- | --- | --- | --- | --- | --- | --- | | ASQ:SE-2 Total score | Above | Monitor | Well Below | Above | Monitor | Well Below | Above | Monitor | Well Below | | Number of scored items with Concern checked | | | | | | | | | | | | Overall concerns indicated | Yes | No | Yes | No | Yes | No | Yes | No | Yes | No | | Parent conference | Yes | No | Yes | No | Yes | No | Yes | No | Yes | No | | Follow-up action/notes | | | | | | | | | | | | Optional: Average item score | | | | | | | | | | |