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 plan ways to meet his/her needs and to help him/her develop. Please return it to school as soon as possible.
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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.
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Person filling out Questionnaire
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 ________________________
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Parents and providers may use the space below for comments.
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.
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