ASQ 9 Month Questionnaire

Please provide the following information. Use black or blue ink only and print legibly when completing this form.

Date ASQ completed:

Baby’s first name

Middle initial

Baby’s last name

Baby’s date of birth

If baby was born 3 or more weeks prematurely, # of weeks premature

Baby’s gender

Male Female

Person filling out questionnaire

First name

Middle initial

Last name

Street address

City

State/ Province

ZIP/ Postal code

Country

Home telephone number

Other telephone number

Relationship to baby

Parent Grandparent or other relative Guardian Foster parent Teacher Child care provider Other

If other, please specify.

Email address

Names of people assisting in questionnaire completion

Program Information

Baby ID #:

Age at administration in months and days:

Program ID #:

If premature, adjusted age in months and days

Program name

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 fill in the circle that indicates whether your baby is doing the activity regularly, sometimes, or not yet.

Important Points to Remember:

Try each activity with your baby before marking a response.
Make completing this questionnaire a game that is fun for you and your baby.
Make sure your baby is rested and fed.
Please return this questionnaire.

Notes

COMMUNICATION

1. Does your baby make sounds like “da,” “ga,” “ka,” and “ba”?

Yes Sometimes Not Yet

Score

2. If you copy the sounds your baby makes, does your baby repeat the same sounds back to you?

Yes Sometimes Not Yet

Score

3. Does your baby make two similar sounds like “ba-ba,” “da-da,” or “ga-ga”? (The sounds do not need to mean anything.)

Yes Sometimes Not Yet

Score

4. If you ask your baby to, does he play at least one nursery game even if you don’t show her the activity yourself (such as “bye-bye,” “Peekaboo,” “clap your hands,” “So Big”)?

Yes Sometimes Not Yet

Score

5. Does your baby follow one simple command, such as “Come here,” “Give it to me,” or “Put it back,” without your using gestures?

Yes Sometimes Not Yet

Score

6. Does your baby say three words, such as “Mama,” “Dada,” and “Baba”? (A “word” is a sound or sounds your baby says consistently to mean someone or something.)

Yes Sometimes Not Yet

Score

COMMUNICATION TOTAL

GROSS MOTOR

1. If you hold both hands just to balance your baby, does she support her own weight while standing?

Yes Sometimes Not Yet

Score

2. When sitting on the floor, does your baby sit up straight for several minutes without using his hands for support?

Yes Sometimes Not Yet

Score

3. When you stand your baby next to furniture or the crib rail, does she hold on without leaning her chest against the furniture for support?

Yes Sometimes Not Yet

Score

4. While holding onto furniture, does your baby bend down and pick up a toy from the floor and then return to a standing position?

Yes Sometimes Not Yet

Score

5. While holding onto furniture, does your baby lower himself with control (without falling or flopping down)?

Yes Sometimes Not Yet

Score

6. Does your baby walk beside furniture while holding on with only one hand?

Yes Sometimes Not Yet

Score

GROSS MOTOR TOTAL

FINE MOTOR

1. Does your baby pick up a small toy with only one hand?

Yes Sometimes Not Yet

Score

2. Does your baby successfully pick up a crumb or Cheerio by using her thumb and all of her fingers in a raking motion? (If she already picks up a crumb or Cheerio, mark “yes” for this item.)

Yes Sometimes Not Yet

Score

3. Does your baby pick up a small toy with the tips of his thumb and fingers? (You should see a space between the toy and his palm.)

Yes Sometimes Not Yet

Score

4. After one or two tries, does your baby pick up a piece of string with her first finger and thumb? (The string may be attached to a toy.)

Yes Sometimes Not Yet

Score

5. Does your baby pick up a crumb or Cheerio with the tips of his thumb and a finger? He may rest his arm or hand on the table while doing it.

Yes Sometimes Not Yet

Score

6. Does your baby put a small toy down, without dropping it, and then take her hand off the toy?

Yes Sometimes Not Yet

Score

FINE MOTOR TOTAL

PROBLEM SOLVING

1. Does your baby pass a toy back and forth from one hand to the other?

Yes Sometimes Not Yet

Score

2. Does your baby pick up two small toys, one in each hand, and hold onto them for about 1 minute?

Yes Sometimes Not Yet

Score

3. When holding a toy in his hand, does your baby bang it against another toy on the table?

Yes Sometimes Not Yet

Score

4. While holding a small toy in each hand, does your baby clap the toys together (like “Pat-a-cake”)?

Yes Sometimes Not Yet

Score

5. Does your baby poke at or try to get a crumb or Cheerio that is inside a clear bottle (such as a plastic soda-pop bottle or baby bottle)?

Yes Sometimes Not Yet

Score

6. After watching you hide a small toy under a piece of paper or cloth, does your baby find it? (Be sure the toy is completely hidden.)

Yes Sometimes Not Yet

Score

PROBLEM SOLVING TOTAL

PERSONAL-SOCIAL

1. While your baby is on her back, does she put her foot in her mouth?

Yes Sometimes Not Yet

Score

2. Does your baby drink water, juice, or formula from a cup while you hold it?

Yes Sometimes Not Yet

Score

3. Does your baby feed himself a cracker or a cookie?

Yes Sometimes Not Yet

Score

4. When you hold out your hand and ask for her toy, does your baby offer it to you even if she doesn’t let go of it? (If she already lets go of the toy into your hand, mark “yes” for this item.)

Yes Sometimes Not Yet

Score

5. When you dress your baby, does he push his arm through a sleeve once his arm is started in the hole of the sleeve?

Yes Sometimes Not Yet

Score

6. When you hold out your hand and ask for her toy, does your baby let go of it into your hand?

Yes Sometimes Not Yet

Score

PERSONAL-SOCIAL TOTAL

OVERALL

Parents and providers may use the space below for additional comments

1. Does your baby use both hands and both legs equally well?

Yes No

If no, explain.

2. When you help your baby stand, are his feet flat on the surface most of the time?

Yes No

If no, explain.

3. Do you have concerns that your baby is too quiet or does not make sounds like other babies?

Yes No

If yes, explain.

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

Yes No

If yes, explain.

5. Do you have concerns about your baby’s vision?

Yes No

If yes, explain.

6. Has your baby had any medical problems in the last several months?

Yes No

If yes, explain.

7. Do you have any concerns about your baby’s behavior?

Yes No

If yes, explain.

8. Does anything about your baby worry you?

Yes No

If yes, explain.

9 Month ASQ-3 Information Summary

Baby’s name

Date ASQ completed

Baby’s ID #

Date of birth

Administering program/provider

Was age adjusted for prematurity when selecting questionnaire?

Yes No

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.

Area

Cut-off

Total Score

Communication

13.97

Gross Motor

17.82

Fine Motor

31.32

Problem Solving

28.72

Personal-Social

18.91

2. TRANSFER OVERALL RESPONSES: Bolded uppercase responses require follow-up. See ASQ-3 User’s Guide, Chapter 6.

1. Uses both hands and both legs equally well?

Yes NO

Comments

2. Feet are flat on the surface most of the time?

Yes NO

Comments

3. Concerns about not making sounds?

YES No

Comments

4. Family history of hearing impairment?

YES No

Comments

5. Concerns about vision?

YES No

Comments

6. Any medical problems?

YES No

Comments

7. Concerns about behavior?

YES No

Comments

8. Other concerns?

YES No

Comments

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 baby’s total score is in the white area, it is above the cutoff, and the baby’s development appears to be on schedule.

If the baby’s total score is in the grey area, it is close to the cutoff. Provide learning activities and monitor.

If the baby’s total score is in the black area, it is below the cutoff. Further assessment with a professional may be needed.

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).

Communication

Gross Motor

Fine Motor

Problem Solving

Personal-Social

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