Please provide the following information. Use black or blue ink only and print legibly when completing this form.
Person filling out questionnaire
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.
Parents and providers may use the space below for additional comments
9 Month ASQ-3 Information Summary
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.
2. TRANSFER OVERALL RESPONSES: Bolded uppercase responses require follow-up. See ASQ-3 User’s Guide, Chapter 6.
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.
5. OPTIONAL: Transfer item responses (Y = YES, S = SOMETIMES, N = NOT YET, X = response missing).
Your information will be encrypted.
Your browser does not support capabilities required for electronic signatures.