www.asqonline.com Open in urlscan Pro
2606:4700::6812:f53  Public Scan

Form analysis
1 forms found in the DOM

POST /family/d7fdd4/questionnaire

<form class="new_family_access_user" id="new_family_access_user" action="/family/d7fdd4/questionnaire" accept-charset="UTF-8" method="post"><input type="hidden" name="authenticity_token"
    value="OHDtN1zjVpl8JhNeWIUJxjgsXRG5m_UBmNIKzEr3c7zMu8SljI7NslJg_hMMaGL0GML-HFQK5j8mXxb3IiKQLw" autocomplete="off"><input type="hidden" name="single" id="single" autocomplete="off">
  <p>
  </p>
  <div>
    <label class="date_field required-field" for="family_access_user_child_dob">Child Date of Birth<span class="required-asterisk">*</span><br>Format: yyyy-mm-dd</label>
    <br>
    <input class="generic_date_field family_access_field hasDatepicker" type="text" name="family_access_user[child_dob]" id="family_access_user_child_dob">
    <span class="hidden" id="future_child_dob_warning" style="font-size: 12px; color: red; display: none;">Child DOB you entered is in the future, are you sure of that? (Please correct the date before proceeding to the next step).</span>
    <span class="hidden" id="child_dob_warning" style="font-size: 12px; color: red; display: none;">Please enter your child's DOB and not the screening date or today's date (Please correct the date before proceeding to the next step).</span>
    <span class="hidden" id="pre_2000_child_dob_warning" style="font-size: 12px; color: red; display: none;">Child DOB you entered is not valid, please format the date like this: YYYY-MM-DD</span>
  </div>
  <p></p>
  <p>
  </p>
  <div>
    <label class="required-field" for="family_access_user_child_weeks_premature">Weeks Premature<span class="required-asterisk">*</span></label>
    <br> (put "0" if not premature) <br>
    <input class="family_access_field" autocapitalize="off" spellcheck="false" type="text" name="family_access_user[child_weeks_premature]" id="family_access_user_child_weeks_premature">
  </div>
  <p></p>
  <p>
  </p>
  <div>
    <label class="date_field required-field" for="family_access_user_screening_date">Screening Date<span class="required-asterisk">*</span></label>
  </div>
  <label style="font-weight: normal" for="date_today"><input type="radio" name="date" id="date_today" value="today"> I am screening my child today (2024-07-25) </label><label style="font-weight: normal" for="date_previous"><input type="radio"
      name="date" id="date_previous" value="previous"> I screened my child and am entering in the responses to a previous screening </label><input class="generic_date_field family_access_field hasDatepicker" placeholder="Enter screening date here"
    type="text" name="family_access_user[screening_date]" id="family_access_user_screening_date" style="display: none;">
  <p></p>
  <p>
    <label for="family_access_user_names_of_people_assisting">List others assisting with completion of the questionnaire</label>
    <br>
    <input class="family_access_field" autocomplete="off" autocapitalize="off" spellcheck="false" type="text" name="family_access_user[names_of_people_assisting]" id="family_access_user_names_of_people_assisting">
  </p>
  <p>
  </p>
  <p>I have read the provided information about the Ages &amp; Stages questionnaires, and I wish to have my child participate in the online screening program. I will fill out the questionnaire about my child's development and promptly submit the
    completed questionnaire through this Family Access online questionnaire completion system.</p>
  <p></p>
  <p> Note: By clicking "Submit", you are agreeing to both our <a href="/legal/ASQ_Online_FAMILY_ACCESS_END_USER_LICENSE_AGREEMENT_02142014.pdf">Family Access End User License Agreement</a> and any other consent or authorization information outlined
    on this page. </p>
  <p>
    <input type="submit" name="commit" value="Submit" id="family_access_user_submit" data-disable-with="Submit">
  </p>
</form>

Text Content

ASQ :: Ages & Stages Questionnaires





PASSAIC COUNTY - PARTNERSHIP FOR MATERNAL & CHILD HEALTH OF NORTHERN NJ
50 UNION AVE SUITE 403
IRVINGTON, NJ 07111
973-942-3630
FULLAURI@PMCH.ORG



DEAR PARENT/CAREGIVER,

CONGRATULATIONS ON TAKING STEPS TO GET A BETTER UNDERSTANDING ABOUT YOUR CHILD’S
GROWTH AND DEVELOPMENT.

WE ARE EXCITED ABOUT YOUR INTEREST IN THIS ONLINE SCREENING TOOL TO HELP YOU
KEEP TRACK OF AND LEARN ABOUT YOUR CHILD'S DEVELOPMENT. THE AGES & STAGES
QUESTIONNAIRES, (ASQ-3), CAN BE USED BY FAMILIES LIVING IN PASSAIC COUNTY WITH
ANY CHILD FROM AGE 1 MONTH TO 5 YEARS. THE QUESTIONS ASK ABOUT SOME THINGS YOUR
CHILD CAN OR CANNOT DO. THERE ARE QUESTIONS ABOUT YOUR CHILD'S:

COMMUNICATION:  HOW YOUR CHILD TALKS



GROSS MOTOR:  HOW YOUR CHILD PLAYS



FINE MOTOR:  HOW YOUR CHILD USES THEIR HANDS



PROBLEM-SOLVING:  HOW YOUR CHILD LEARNS



PERSONAL/SOCIAL SKILLS:  HOW YOUR CHILD INTERACTS WITH THEIR WORLD

WITHIN A FEW DAYS AFTER WE RECEIVE YOUR COMPLETED ASQ-3, WE WILL CONTACT YOU TO
SHARE THE RESULTS AND OFFER FOLLOW-UP ACTIVITIES AND RESOURCES.


TO USE THIS ONLINE SCREENING TOOL, BEGIN BY ENTERING YOUR INFO BELOW AND
CLICKING "SUBMIT”.

WE LOOK FORWARD TO YOUR PARTICIPATION IN ASQ-3!

SINCERELY,

PARTNERSHIP FOR MATERNAL & CHILD HEALTH OF NORTHERN NJ (A PROGRAM OF HELP ME
GROW NJ)



THE WEEKS PREMATURE FIELD BELOW REFERS TO HOW MANY WEEKS EARLY YOUR CHILD WAS
BORN.  BASED ON 40 WEEKS BEING FULL TERM, IF YOUR CHILD WAS BORN AT 36 WEEKS OR
EARLIER BE SURE TO PUT IN HOW MANY WEEKS EARLY.  EXAMPLE: IF YOUR CHILD IS BORN
AT 35 WEEKS, PUT IN 5 WEEKS; IF YOUR CHILD IS BORN AT 32 WEEKS, PUT IN 8 WEEKS.

IF YOU HAVE ANY QUESTIONS, PLEASE BE SURE TO CONTACT US AT: 973-942-3630



Child Date of Birth*
Format: yyyy-mm-dd
Child DOB you entered is in the future, are you sure of that? (Please correct
the date before proceeding to the next step). Please enter your child's DOB and
not the screening date or today's date (Please correct the date before
proceeding to the next step). Child DOB you entered is not valid, please format
the date like this: YYYY-MM-DD





Weeks Premature*
(put "0" if not premature)






Screening Date*
I am screening my child today (2024-07-25) I screened my child and am entering
in the responses to a previous screening



List others assisting with completion of the questionnaire




I have read the provided information about the Ages & Stages questionnaires, and
I wish to have my child participate in the online screening program. I will fill
out the questionnaire about my child's development and promptly submit the
completed questionnaire through this Family Access online questionnaire
completion system.



Note: By clicking "Submit", you are agreeing to both our Family Access End User
License Agreement and any other consent or authorization information outlined on
this page.






Copyright and Terms of Use

Copyright © 2009-2024 Paul H. Brookes Publishing Co., Inc. All rights reserved.



Application Release 2024-07-11


loading