P101360800
3. 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 appropriate follow-up.
If the child’s total score is in the area, it is above the cutoff, and the child’s development appears to be on schedule.
If the child’s total score is in the area, it is close to the cutoff. Provide learning activities and monitor.
If the child’s total score is in the area, it is below the cutoff. Further assessment with a professional may be needed.
Child’s name: ________________________________________________________
Child’s ID #: ______________________________________________________
Administering program/provider:
Month ASQ-3 Information Summary
36
34 months 16 days through
38 months 30 days
Communication
Gross Motor
Fine Motor
Problem Solving
Personal-Social
123456
2. TRANSFER OVERALL RESPONSES: Bolded uppercase responses require follow-up. See
ASQ-3 User’s Guide,
Chapter 6.
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
Gross Motor
Fine Motor
Problem Solving
Personal-Social
0 5 10 15 20 25 30 35 40 45 50 55 60
Total
Area Cutoff Score
30.99
36.99
18.07
30.29
35.33
4. FOLLOW-UP ACTION TAKEN: Check 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
______ Other (specify): ____________________________________________________
5. OPTIONAL: Transfer item responses
(Y = YES, S = SOMETIMES, N = NOT YET,
X = response missing).
1. Hears well? Yes NO
Comments:
2. Talks like other children his age? Yes NO
Comments:
3. Understand most of what your child says? Yes NO
Comments:
4. Others understand most of what your child says? Yes NO
Comments:
5. Walks, runs, and climbs like other children? Yes NO
Comments:
6. Family history of hearing impairment? YES No
Comments:
7. Concerns about vision? YES No
Comments:
8. Any medical problems? YES No
Comments:
9. Concerns about behavior? YES No
Comments:
10. Other concerns? YES No
Comments:
Date ASQ completed: __________________________________________
Date of birth: ______________________________________________
Ages & Stages Questionnaires
®
, Third Edition (ASQ
®
-3), Squires & Bricker..
© 2009 Paul H. Brookes Publishing Co. All rights reserved.
Authorized alternate format for use 4/1/20−9/1/20. No web posting permitted.
