ED15 ASQ Results for ChildPlus

ASQ-3 and ASQ:SE
Results For Child Plus
Child’s Name
Birthdate
Staff Name
Site
Screening Results
Screening
Information
Behavioral Screening (ASQ:SE)
Date of
Screening:

Initial Screening (within 45 days
of enrollment)

First Screening of program year
(September) for returning
children
__________
Screening Tool Used:
6 month ASQ:SE
12 month ASQ:SE
18 month ASQ:SE
24 month ASQ:SE
30
36
48
60
month
month
month
month
ASQ:SE
ASQ:SE
ASQ:SE
ASQ:SE
 Rescreen
Use this area if this is the child’s initial screening or the first
screening of the program year
Rescreen (within 90 days of enrollment): Use this area if the
 Passed -score was not above the cutoff score – no
concerns at this time (P)
 Rescreened: Passed – score was not above the cutoff score –
no concerns at this time (Q)
 Failed–score was higher than the cutoff score:
 Child is receiving MH Services (L)
 Will refer to behavioral health or mental health
agency-complete FS05 (F)
 Will monitor and rescreen within 45 days (N)
 Rescreened: Failed – score was higher than the cutoff score:
 Child is receiving MH Services (L)
 Will refer to behavioral health or mental health agencycomplete FS05 (G)
 Parent choosing not to refer to outside agency for
additional assessment/services(D)
child did not pass the previous behavioral screening
 Parent refused screening (B)
Screening
Information
Developmental Screening (ASQ-3)
Date of
Screening:

Initial Screening (within 45 days of
enrollment)

First Screening of program year
(September) for returning children

Rescreen
__________
Screening Results
Use this area if this is the child’s initial screening or the first
screening of the program year
 Passed all areas–no concerns at this time (P)
 Failed one or more areas (black or shaded areas):
 Will refer to outside agency-complete DI10 (F)
 Will monitor and rescreen within 45 days (N)
 Further evaluation is already In Process or
Completed (submit documentation) (L)
 Child has a valid IFSP/IEP (L)
Note: Child with a current IEP/IFSP does not need to be
screened.
Screening Tool Used:
2 month ASQ-3
14
4 month ASQ-3
16
6 month ASQ-3
18
8 month ASQ-3
20
9 month ASQ-3
22
10 month ASQ-3 24
12 month ASQ-3 27
month
month
month
month
month
month
month
ASQ-3
ASQ-3
ASQ-3
ASQ-3
ASQ-3
ASQ-3
ASQ-3
30
33
36
42
48
54
60
month
month
month
month
month
month
month
ASQ-3
ASQ-3
ASQ-3
ASQ-3
ASQ-3
ASQ-3
ASQ-3
Rescreen(within 90 days of enrollment): Use this area if
the child failed one or more developmental areas at the previous
screening
 Rescreened: Passed all areas – no longer concerns in any
area (Q)
 Rescreened: Failed one or more areas (black or shaded
areas):
 Will refer to outside agency-complete DI10 (G)
 Parent choosing not to refer to outside agency for
additional assessment/services (D)
 Did not Rescreen – further evaluation is already In Process or
Completed (submit documentation) (L)
 Parent refused screening (B)
Data Entry: __________________
ED15 8-15-14
INSTRUCTIONS TO COMPLETE THIS FORM
FORM NAME:
ASQ-3 and ASQ:SE Results for ChildPlus (ED15)
PURPOSE:
To document the ASQ-3 and ASQ:SE screening for data entry into ChildPlus
WHO FILLS OUT:
Classroom Staff or Home Base Teacher
HOW TO COMPLETE:

complete the top portion with child’s name, birthdate and the name of
the staff/ home base teacher

In the “screening information” boxes, fill in the date of the screening,
indicate which screening was completed and the tool that was used

In the “screening results” boxes, fill in the results of the screening. Use
the left-hand box if this is the initial screening or there have been no
concerns on the previous screening. Use the “rescreen” box if there
were concerns on a previous screening.

The form is filled out as soon as the screening is complete. If both
screenings are completed close together (within 1-2 weeks) both can
be documented on one form. If there is a gap between the screenings,
or only one screening is complete, send in the form upon completion.

Original form is kept in the Education/Disabilities/Mental Health section
of the child’s file and copy is scanned to the Education/ Disabilities
Coordinator
WHEN TO COMPLETE:
After completion of the ASQ-3 and ASQ:SE screening
SUBMIT TO:
Education/ Disabilities Coordinator
PAPER SIZE
Letter
PAPER TYPE
20 lb
PAPER COLOR
White
ASSEMBLY
2 sided
ED15 8-15-14

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