ASQ Online Family Consent Form 2020/2021
The Massachusetts Department of Early Education and Care (EEC) and South Berkshire Kids/CFCE would like to invite you to engage in developmental screening with your child using the Ages and Stages Questionnaire (ASQ). Developmental screening provides families the opportunity to share and learn about their child’s development, to celebrate their growth, and to address any questions or concerns they may have about what “typical” development looks like. The ASQ is designed to be filled out by families. It is user-friendly, and should only take about 10 minutes to complete. It can be filled out on paper or online. Your child’s early education and care program can also do it with you in person, and provide you with the results.

ASQ has been used for more than 20 years to make sure children are developing well. It looks at how children are doing in important areas, such as speech, physical ability, social skills, and problem-solving skills. Results can help inform the family of one of three things for each of the five domains: the child is developmentally on track; the child's progress needs monitoring and possible supportive activities; or the child needs further assessment by a pediatrician or early intervention. ASQ 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. There are 2 sets of questionnaires: ASQ-3 which looks at overall total development and ASQ:SE-2 which looks more closely at social and emotional development. You are welcome to complete just one or both!!

ASQ can be used with children from 1 month to 5 ½ years old and can be done at multiple intervals during your child’s first five years of life! If your child has trouble with some skills, South Berkshire Kids/CFCE will help you with next steps. You are an active partner in your child’s learning and development.

The Consent Form below requests your permission to do developmental screening with your child, and to enter your child's screening data into an online database. Using that data, your child’s early education and care program can look at your child’s development, and can connect you with community resources to support your child, if needed. The Consent Form also requests your permission to share the data with EEC. The combined data from developmental screening across the Commonwealth helps inform the ways EEC supports educators and families to respond to children’s needs through training and resources. Please note that EEC will combine the data of many children and will not be able to identify specific individual children. Screening data will be confidential to ensure your privacy. If you do not wish to have information entered online and shared with EEC, you may decline this option and your child may still be screened using the ASQ paper questionnaire.

If you choose to participate in any of these developmental screening activities, please complete the Consent Form below. Thank you! And if you choose not to…please also let us know why below.

**Please read the text below and check the desired Questionnaires you would like to complete:

I have read the provided information about the Ages & Stages Questionnaires (ASQ), and I wish to have my child(ren) participate in the monitoring program. I will fill out the questionnaires about my child’s development and promptly return the completed questionnaires.
Please choose one option below. *
If "not interested" please indicate below the reason(s) why you are not interested?
Clear selection
2 ways to complete the ASQ:
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Parent/Guardian Name (First & Last) *
Mailing Address (Street address, city, state, zip code):
Email: *
Please provide your child's name & date of birth (please note if child was premature more than 3 weeks).
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