Please help us get to know your child by filling out this form. All the information will be confidential. We will use what you tell us as we begin to get to know your child and p l a n wa y s t o m eet hi s / h er n e e d s and t o h e l p h i m /h er develop. Please return it to school as soon as possible. Thanks so much! Childs Name Childs Nickname Parents’ Names Date
Date Format: MM slash DD slash YYYY
Child’s Teacher Does your child live with? Please Specify Please list the names and ages of others who live in your home. (This will help me write names correctly on pictures your child draws about his/her family.) Pets (Name & type of animal) Father’s Occupation Mother's Occupation Does your child have a room of his own? If not, with whom does he/she share a room? What are your child’s favourite play activities and interests? Does child use special words to go to the bathroom? Child’s favorite TV programs Hours per day spent watching TV Does your child usually play Does child have decided fears? If so, what? What responsibilities does your child have at home? What is your biggest discipline problem? What is your child’s favorite story or type of story or book? Did your child have a premature or difficult birth that may indicate cognitive delays? Is English the primary language spoken in the home? If not, what is? Does your child speak any English? Understand English? How does your child feel about coming to school? What do you hope your child will learn this year? Please make comments about anything else you think I need to know about your child It is our goal to encourage a sense of belongingness, promote an appreciation of others and enrich children’s experiences by integrating into our curriculum activities and information that reflect our individual children’s background. One way we can do this is by learning about each child’s family background, celebrated holidays, and traditions. Please take a few minutes to share with us your special family days or activities and how they are carried out in your home. What languages other than English are spoken by family members around your child? Does your child have any physical or learning disabilities? If so, please describe Are there any family members with disabilities that may directly impact your child’s daily life (for example, a deaf grandparent, wheelchair bound parent, etc.)? What information about your family’s background and culture would you like to share with us? What are the holidays, special days, or traditions your family partakes in? Are there any special foods, songs, items or symbols you include in your celebration of special family times? Does your child have any dietary restrictions due to allergies, intolerances, family or religious preferences? If yes, what is restricted? Are there any activities from your family’s culture or traditions that you would like to share with your child’s classroom? Are there any activities from your family’s culture or traditions that you would like to share with your child’s classroom? Please make comments about anything else you think I need to know about your child What are their strengths? What are the areas of weakness? What would you love for your child to get better at? My child learns best when the teacher is…. My child does not work well with… What is the best way to motivate your child? What are you looking forward to at YMIM? How would you like to be involved with your child’s education? What is your preferred method of communication (email, phone call, meeting, note…)___ Date ASQ Completed:
Date Format: DD slash MM slash YYYY
Child’s date of birth:
Date Format: MM slash DD slash YYYY
Is It a Boy Or a Girl? Person filling out Questionnaire First Name Middle Initial Last Name Street Address Relationship to child: City : State / Province: Zip / Postal Code: Country Home telephone number: Other telephone number: Email Address Name of the people assisting in questionnaire completion: Program Information Child ID # Program ID # Program Name Important Points to Remember:
Try each activity with your child before marking a response.
Make completing this questionnaire a game that is fun for you and your child.
Make sure your child is not tired or hungry.
Please return this questionnaire by ________________________ Notes 1. Does your child name at least three items from a common category? For example, if you say to your child, “Tell me some things that you can eat,” does your child answer with something like “cookies, eggs, and cereal”? Or if you say, “Tell me the names of some animals,” does your child answer with something like “cow, dog, and elephant”? 2. Does your child answer the following questions? (Mark “sometimes” if your child answers only one question.) “What do you do when you are hungry?” (Acceptable answers include “get food,” “eat,” “ask for something to eat,” and “have a snack.”) Please write your child’s response: “What do you do when you are tired?” (Acceptable answers include “take a nap,” “rest,” “go to sleep,” “go to bed,” “lie down,” and “sit down.”) Please write your child’s response: 3. Does your child tell you at least two things about common objects? For example, if you say to your child, “Tell me about your ball,” does she say something like, “It’s round. I throw it. It’s big”? 4. Does your child use endings of words, such as “-s,” “-ed,” and “-ing”? For example, does your child say things like, “I see two cats,” “I am playing,” or “I kicked the ball”? Communication ( Continued ) 5. Without your giving help by pointing or repeating, does your child fol- low three directions that are unrelated to one another? Give all three directions before your child starts. For example, you may ask your child, “Clap your hands, walk to the door, and sit down,” or “Give me the pen, open the book, and stand up.” 6. Does your child use all of the words in a sentence (for example, “a,” “the,” “am,” “is,” and “are”) to make complete sentences, such as “I am going to the park,” or “Is there a toy to play with?” or “Are you coming, too?” Communication Total GROSS MOTOR 1. Does your child catch a large ball with both hands? (You should stand about 5 feet away and give your child two or three tries before you mark the answer.) 2. Does your child climb the rungs of a ladder of a playground slide and slide down without help? 3. While standing, does your child throw a ball overhand in the direction of a person standing at least 6 feet away? To throw overhand, your child must raise his arm to shoulder height and throw the ball forward. (Dropping the ball or throwing the ball underhand should be scored as “not yet.”) 4. Does your child hop up and down on either the right or left foot at least one time without losing her balance or falling? 5. Does your child jump forward a distance of 20 inches from a standing position, starting with his feet together? 6. Without holding onto anything, does your child stand on one foot for at least 5 seconds without losing her balance and putting her foot down? (You may give your child two or three tries before you mark the answer.) Gross Motar Total Fine Motor 1. Does your child put together a five- to seven-piece interlocking puzzle? (If one is not available, take a full-page picture from a magazine or catalog and cut it into six pieces. Does your child put it back together correctly?) 2. Using child-safe scissors, does your child cut a paper in half on a more or less straight line, making the blades go up and down? (Carefully watch your child’s use of scissors for safety reasons.) 3. Using the shapes below to look at, does your child copy at least three shapes onto a large piece of paper using a pencil, crayon, or pen, with- out tracing? (Your child’s drawings should look similar to the design of the shapes below, but they may be different in size.) 4. Does your child unbutton one or more buttons? (Your child may use his own clothing or a doll’s clothing.) 5. Does your child draw pictures of people that have at least three of the following features: head, eyes, nose, mouth, neck, hair, trunk, arms, hands, legs, or feet? 6. Does your child color mostly within the lines in a coloring book or within the lines of a 2-inch circle that you draw? (Your child should not go more than 1/4 inch outside the lines on most of the picture.) Fine Motor Total Problem Solving 1. When you say, “Say ‘five eight three,’” does your child repeat just the three numbers in the same order? Do not repeat the numbers. If neces- sary, try another series of numbers and say, “Say ‘six nine two.’” (Your child must repeat just one series of three numbers to answer “yes” to this question.) 2. When asked, “Which circle is the smallest?” does your child point to the smallest circle? (Ask this question withoutproviding help by point- ing, gesturing, or looking at the smallest circle.) 3. Without your giving help by pointing, does your child follow three dif- ferent directions using the words “under,” “between,” and “middle”? For example, ask your child to put the shoe “under the couch.” Then ask her to put the ball “between the chairs” and the book “in the middle of the table.” 4. When shown objects and asked, “What color is this?” does your child name five different colors, like red, blue, yellow, orange, black, white, or pink? (Mark “yes” only if your child answers the question correctly using five colors.) 5. Does your child dress up and “play-act,” pretending to be someone or something else? For example, your child may dress up in different clothes and pretend to be a mommy, daddy, brother, or sister, or an imaginary animal or figure. 6. If you place five objects in front of your child, can he count them by saying, “one, two, three, four, five,” in order? (Ask this question without providing help by pointing, gesturing, or naming.) Personal Social 1. Does your child serve herself, taking food from one container to an- other using utensils? For example, does your child use a large spoon to scoop applesauce from a jar into a bowl? 1. Does your child serve herself, taking food from one container to an- other using utensils? For example, does your child use a large spoon to scoop applesauce from a jar into a bowl? 2. Does your child tell you at least four of the following? Please mark the items your child knows. 3. Does your child wash his hands using soap and water and dry off with a towel without help? 4. Does your child tell you the names of two or more playmates, not in- cluding brothers and sisters? (Ask this question without providing help by suggesting names of playmates or friends.) 5. Does your child brush her teeth by putting toothpaste on the tooth- brush and brushing all of her teeth without help? (You may still need to check and rebrush your child’s teeth.) 6. Does your child dress or undress himself without help (except for snaps, buttons, and zippers)? Personal Social Total Overall
Parents and providers may use the space below for comments.
1. Do you think your child hears well? If no, explain: 2. Do you think your child talks like other children her age? If no, explain: 3. Can you understand most of what your child says? If no, explain: 4. Can other people understand most of what your child says? If no, explain: 5. Do you think your child walks, runs, and climbs like other children his age? If no, explain: 6. Does either parent have a family history of childhood deafness or hearing impairment? If yes, explain: 7. Do you have any concerns about your child’s vision? If yes, explain: 8. Has your child had any medical problems in the last several months? If yes, explain: 9. Do you have any concerns about your child’s behavior? If yes, explain: 10. Does anything about your child worry you? If yes, explain: 1. SCORE AND TRANSFER TOTALS TO CHART BELOW:
See ASQ-3 User’s Guide for
details, including how to adjust scores if item
responses are missing. Score each item (YES = 10, SOMETIMES = 5, NOT YET = 0).
Add item scores, and record each area total.
In the chart below, transfer the total scores, and fill in the circles corresponding with the total scores.
Communication " Cutt Off: 30.72 " Gross Motor " Cutt Off: 32.78 " Fine Motor " Cutt Off: 15.81 " Problem Solving " Cutt Off: 31.30 " Personal Solcial " Cutt Off: 26.60 " 1. Hears well? 2. Talks like other children his age? 3. Understand most of what your child says ? 4. Others understand most of what your child says? 5. Walks, runs, and climbs like other children? 6. Family history of hearing impairment? 7. Concerns about vision? 8. Any medical problems? 9. Concerns about behavior? 9. Concerns about behavior? 10 Other concerns? ASQ SCORE INTERPRETATION AND RECOMMENDATION FOR FOLLOW-UP
You must consider total area scores, overall
responses, and other considerations, such as opportunities to practice skills, to determine the appropriate follow-up.
If the child’s total score is above 40 it is above the cutoff and the child’s development appears to be on schedule. If the child’s total score is above 15, but less than 40 it is above the cutoff and the child’s development appears to be on schedule. If the child’s total score is below 15, it is below the cutoff.
Further assessment with a professional may be needed. 4.FOLLOW-UP ACTION TAKEN:
Fill all that apply
Provide activities and rescreen in ________ months. Share results with primary health care provider Refer for (circle all that apply) hearing, vision, and/or behavioral screening. Refer to primary health care provider or other community agency (specify reason): Refer to early intervention/early childhood special education. No further action taken at this time