ASQ Screening

For 9, 18, 24 & 30 Months of Age

Index Child

Complete this form along with an age appropriate screen during each of the following intervals:

between child’s age of 9 months 0 days through 9 months 30 days;

between child’s age of 17 months 0 days through 18 months 30 days;

between child’s age of 23 months 0 days through 25 months 15 days;

between child’s age of 28 months 16 days through 31 months 15 days.

Name of Home Visitor:

Home Visiting Program:	Early Head Start	Healthy Families Oregon

Child ID #:

Name of Index Child:

Name of Index Parent:

Part A: Developmental Screening

To meet Developmental Screening Measure: Child must receive an age-appropriate, on-time ASQ Screening, unless child has a previously identified developmental delay (prior to enrollment or prior to reaching this age-recommended screening).

ASQ Screening Completed?

Yes, completed → Date ASQ Screening scored and discussed with parent: / / 20 → Complete Questions 2-4.

No, not completed → Complete Questions 1a & b.

1a. If No, reason why ASQ Screening was not completed:

Child has a previously identified developmental delay (an ASQ screening is not required).

No, other reason → If possible, complete Screening at future visit before the window closes, then complete another ASQ Screening form and update in THEO.

1b. If ASQ Screening not completed, date Question 1a completed: / / 20

2.	Age level of ASQ Questionnaire used: Months.

3.	Scoring:

DOMAIN	TOTAL Domain Score
Communication
Gross Motor
Fine Motor
Problem Solving
Personal-Social

Part B: Developmental Referrals

4.	Do ASQ Screening scores indicate child is at risk for developmental delay? Child is at risk if they score 2 or more domains in gray (monitoring), or 1 or more domains in black (at-risk), or a combination of these.

Yes → A referral is required: Complete ASQ-Referral Tracking & Follow-up Form.	No