ASQ_24 M

Child’s first name:

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Middle initial:

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Child’s last name:

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Child’s date of birth:

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Child’s gender:

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Person filling out questionnaire

First name:

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Middle initial:

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Last name:

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Street address:

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Relationship to child:

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If Other, please specify:

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City:

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State/ Province:

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ZIP/ Postal code:

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Country:

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Home telephone number:

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Other telephone number:

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Names of people assisting in questionnaire completion:

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Program Information

Child ID #:

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Program ID #:

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Program name:

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On the following pages are questions about activities babies may do. Your baby may have already done some of the activities described here, and there may be some your baby has not begun doing yet. For each item, please choose an option that indicates whether your baby is doing the activity regularly, sometimes, or not yet.

Important Points to Remember:

Tryeachactivitywithyourbabybeforemarkingaresponse.
Make completing this questionnaire a game that is fun for you and your child.
Make sure your child is rested and fed.

COMMUNICATION

1. Without you showing him, does your child point to the correct picture when you say, " Show me the kitty," or ask, "Where is the dog?" (She needs to identify only one picture correctly.)

Please select an option.

2. Does your child imitate a two-word sentence? For example, when you say a two-word phrase, such as "Mama eat," "Daddy play," "Go home," or "What's this?" does your child say both words back to you? (Mark "yes" even if her words are difficult to understand.)

Please select an option.

3. Without your giving him clues by pointing or using gestures, can your child carry out at least three of these kinds of directions?

Please select an option.

“Put the toy on the table.”
“Close the door.”
“Bring me a towel.”
“Find your coat.”
“Take my hand.”
“Get your book.”

4. If you point to a picture of a ball (kitty, cup, hat, etc.) and ask your child, "What is this?" does your child correctly name at least one picture?

Please select an option.

5. Does your child say two to three words that represent different ideas together, such as "See dog," "Mommy come home," or "Kitty gone" ? (Don't count word combinations that express one idea, such as "bye-bye," "all gone," "all right," and "What's that?")

Please select an option.

Please give an example of your child's word combinations:

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6. Does your child correctly use at least two words like "me," "I," "mine," and "you"?

Please select an option.

GROSS MOTOR

1. Does your child walk down stairs if you hold onto one of her hands? She may also hold onto the railing or wall. (You can look for this at a store, on a playground, or at home.)

Please select an option.

2. When you show your child how to kick a large ball, does he try to kick the ball by moving his leg forward or by walking into it? (If your child already kicks a ball, mark "yes" for this item.)

Please select an option.

3. Does your child walk either up or down at least two steps by herself? She may hold onto the railing or wall.

Please select an option.

4. Does your child run fairly well, stopping herself without bumping into things or falling?

Please select an option.

5. Does your child jump with both feet leaving the floor at the same time?

Please select an option.

6. Without holding onto anything for support, does your child kick a ball by swinging his leg forward?

Please select an option.

FINE MOTOR

1. Does your child get a spoon into his mouth right side up so that the food usually doesn't spill?

Please select an option.

2. Does your child turn the pages of a book by herself? (She may turn more that one page at a time.)

Please select an option.

3. Does your child use a turning motion with his hand while trying to turn doorknobs, wind up toys, twist tops, or screw lids on and off jars?

Please select an option.

4. Does your child flip switches off and on?

Please select an option.

5. Does your child stack seven small blocks or toys on top of each other by herself? (You could also use spools of thread, small boxes, or toys that are about 1 inch in size.)

Please select an option.

6. Can your child string small items such as beads, macaroni, or pasta “wagon wheels” onto a string or shoelace?

Please select an option.

PROBLEM SOLVING

1. After watching you draw a line from the top of the paper to the bottom with a crayon (or pencil or pen), does your child copy you by drawing a single line on the paper in any direction? (Mark "not yet" if your child scribbles back and forth.)

Please select an option.

2. After a crumb or Cheerio is dropped into a small, clear bottle, does your turn the bottle upside down to dump out the crumb or Cheerio? (Do not show him how.) (You can use a soda-pop bottle or baby bottle.)

Please select an option.

3. Does your child pretend objects are something else? For example, does your child hold a cup to her ear, pretending it is a telephone? Does she put a box on her head, pretending it is a hat? Does she use a block or small toy to stir food?

Please select an option.

4. Does your child put things away where they belong? For example, does he know his toys belong on the toy shelf, his blanket goes on his bed. and dishes go in the kitchen?

Please select an option.

5. If your child wants something he cannot reach, does he find a chair or box to stand on to reach it (for example, to get a toy on a counter or to “help” you in the kitchen)?

Please select an option.

6. While your child watches, line up four objects like blocks or cars in a row. Does your child copy or imitate you and line up four objects in a row? (You can also use spools of thread, small boxes or other toys.)

Please select an option.

PERSONAL-SOCIAL

1. Does your child drink from a cup or glass, putting it down again with little spilling?

Please select an option.

2. Does your child copy the activities you do, such as wipe up a spill, sweep, shave or comb hair?

Please select an option.

3. Does your child eat with a fork?

Please select an option.

4. When playing with either a stuffed animal or a doll, does your child pretend to rock it, feed it, change its diapers, put it to bed, and so forth?

Please select an option.

5. Does your child push a little wagon, stroller, or other toy on wheels, steering it around objects and backing out of corners if she cannot turn?

Please select an option.

6. Does your child call herself "I" or "me" more often than her own name? For example, "I do it," more often than "Juanita do it."

Please select an option.

OVERALL

1. Do you think your child hears well?

Please select an option.

If no, explain:

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2. Do you think your child talks like other toddlers her age?

Please select an option.

If no, explain:

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3. Can you understand most of what your child says?

Please select an option.

If no, explain:

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4. Do you think your child walks, runs, and climbs like other toddlers his age?

Please select an option.

If no, explain:

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5. Does either parent have a family history of childhood deafness or hearing impairment?

Please select an option.

If yes, explain:

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6. Do you have any concerns about your child’s vision?

Please select an option.

If yes, explain:

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7. Has your child had any medical problems in the last several months?

Please select an option.

If yes, explain:

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8. Do you have any concerns about your child’s behavior?

Please select an option.

If yes, explain:

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9. Does anything about your child worry you?

Please select an option.

If yes, explain:

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Please sign your name in the area below

By submitting your signature, the parties agree that this agreement may be electronically signed. The parties agree that the electronic signatures appearing on this agreement are the same as handwritten signatures for the purposes of validity, enforceability, and admissibility.

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