# Kansas Statewide ASQ® System

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Ages & Stages Questionnaires®, Third Edition (ASQ®-3) and Ages & Stages Questionnaires®: Social-Emotional, Second Edition (ASQ®:SE-2)

**ORDER FORM** – For product information, sample questionnaires and other support resources, visit [http://agesandstages.com/ks/](/content/ks/index.html). Prices Valid through June 30, 2027

## CORE RESOURCES

| Stock # | Product Name | Unit Cost | Qty | Ext Price |
| --- | --- | --- | --- | --- |
| 70410 | ASQ-3 English Starter Kit | $265.00 |  |  |
| 70038 | ASQ-3 Spanish Questionnaires | $216.00 |  |  |
| 72469 | ASQ-3 Learning Activities | $44.96 |  |  |
| 72476 | ASQ-3 Learning Activities in Spanish | $44.96 |  |  |
| 79611 | ASQ:SE-2 English Starter Kit | $265.00 |  |  |
| 79574 | ASQ:SE-2 Spanish Questionnaires | $216.00 |  |  |
| 69780 | ASQ:SE-2 Learning Activities & More | $44.96 |  |  |
| 52735 | ASQ:SE-2 Learning Activities & More in Spanish | $44.96 |  |  |

## OPTIONAL ADDITIONAL RESOURCES

| Stock # | Product Name | Unit Cost | Qty | Ext Price |
| --- | --- | --- | --- | --- |
| 52650 | ASQ-3 Vietnamese Questionnaires | $157.50 |  |  |
| 55095 | ASQ:SE-2 Vietnamese Questionnaires | $157.50 |  |  |
| 52643 | ASQ-3 Arabic Questionnaires | $157.50 |  |  |
| 53640 | ASQ:SE-2 Arabic Questionnaires | $157.50 |  |  |
| 53367 | ASQ-3 Chinese Questionnaires | $157.50 |  |  |
| 55101 | ASQ:SE-2 Chinese Questionnaires (available in Fall 2026) | $157.50 |  |  |
|  | SUBTOTAL |  |  |  |
| Shipping at 10% of subtotal |  |  |  |  |
| TOTAL |  |  |  |  |

Reference list code KSASQ2026 to receive the discounted pricing and shipping shown above.

## SHIP TO INFORMATION:

Name____ Organization ____

Address ____City____State ____Zip____

Credit Card Number ____

Email ____

Purchase Order # __________________________(must include/attach a copy of the P.O.)

Tel ____

1. Toll Free: 800-638-3775 (Customer Service) (credit card orders only)
2. Email: order@brookespublishing.com (purchase orders only)
3. Fax: 410-337-8539 (credit cards or purchase orders)