ASQ 60 Month Questionnaire

Date ASQ completed

Child's information

Child's first name:

Middle initial

Child's last name

Child's date of birth

Child'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 child

Parent Guardian Teacher Child care Provider Grandparent or other relative Foster parent other

If other, please specify.

Email address

Names of people assisting in questionnaire completion

PROGRAM INFORMATION

Child ID #

Program ID #

Program name

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

Important Points to Remember:

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

Notes

COMMUNICATION

1. Without your giving help by pointing or repeating directions, does your child follow three directions that are unrelated to one another? Give all three directions before your child starts. For example, you may ask your child, "Clap your hands, walk to the door, and sit down," or "Give me the pen, open the book, and stand up."

Yes Sometimes Not Yet

2. Does your child use four- and five-word sentences? For example, does your child say, "I want the car"? Please write an example:

Yes Sometimes Not Yet

3. When talking about something that already happened, does your child use words that end in "-ed," such as "walked,* jumped, or played ? Ask your child questions, such as "How did you get to the store?" ("We walked.") "What did you do at your friend's house?" ("We played.") Please write an example:

Yes Sometimes Not Yet

4. Does your child use comparison words, such as "heavier," "stronger," or "shorter"? Ask your child questions, such as "A car is big, but a bus is_____" (bigger); "A cat is heavy, but a man is_____" (heavier); "A TV is small, but a book is. (smaller). Please write an example:

Yes Sometimes Not Yet

5. Does your child answer the following questions? (Mark "sometimes" if your child answers only one question.)

Yes Sometimes Not Yet

"What do you do when you are hungry?" (Acceptable answers include "get food," "eat," "ask for something to eat," and "have a snack.") Please write your child's response;

"What do you do when you are tired?" (Acceptable answers include: "take a nap," "rest," "go to sleep," "go to bed," "lie down," and "sit down.") Please write your child's response:

6. Does your child repeat the sentences shown below back to you, without any mistakes? (Read the sentences one at a time. You may repeat each sentence one time. Mark "yes" ifyour child repeats both sentences without mistakes or "sometimes" ifyour child repeats one sentence without mistakes.)

Yes Sometimes Not Yet

Jane hides her shoes for Maria to find.

Al read the blue book under his bed.

COMMUNICATION TOTAL

GROSS MOTOR

1. While standing, does your child throw a ball overhand in the direction of a person standing at least 6 feet away? To throw overhand, your child must raise his arm to shoulder height and throw the ball forward. (Dropping the ball or throwing the ball underhand should be scored as "not yet.")

Yes Sometimes Not Yet

2. Does your child catch a large ball with both hands? (You should stand about 5 feet away and give your child two or three tries before you mark the answer.)

Yes Sometimes Not Yet

3. Without holding onto anything, does your child stand on one foot for at least 5 seconds without losing her balance and putting her foot down? (You may give your child two or three tries before you mark the answer.)

Yes Sometimes Not Yet

4. Does your child walk on his tiptoes for 15 feet (about the length of a large car)? (You may show him how to do this.)

Yes Sometimes Not Yet

5. Does your child hop forward on one foot for a distance of 4-6 feet without putting down the other foot? (You may give her two tries on each foot. Mark "sometimes" if she can hop on one foot only.)

Yes Sometimes Not Yet

6. Does your child skip using alternating feet? (You may show him how to do this.)

Yes Sometimes Not Yet

GROSS MOTOR TOTAL

FINE MOTOR

1. Ask your child to trace on the line below with a pencil. Does your child trace on the line without going off the line more than two times? (Mark "sometimes" if your child goes off the line three times.)

Yes Sometimes Not Yet

2. Ask your child to draw a picture of a person on a blank sheet of paper. You may ask your child, "Draw a picture of a girl or a boy." If your child draws a person with head, body, arms, and legs, mark "yes." If your child draws a person with only three parts (head, body, arms, or legs), mark "sometimes." If your child draws a person with two or fewer parts (head, body, arms, or legs), mark "not yet." Be sure to include the sheet of paper with your child's drawing with this questionnaire.

Yes Sometimes Not Yet

3. Draw a line across a piece of paper. Using child-safe scissors, does your child cut the paper in half on a more or less straight line, making the blades go up and down? (Carefully watch your child's use of scissors for safety reasons.)

Yes Sometimes Not Yet

4. Using the shapes below to look at, does your child copy the shapes in the space below without tracing? (Your child's drawings should look similar to the design of the shapes below, but they may be different in size. Mark "yes" ifshe copies all three shapes; mark "sometimes" if your child copies two shapes.)

Yes Sometimes Not Yet

5. Using the letters below to look at, does your child copy the letters without tracing? Cover up all of the letters except the letter being copied. (Mark "yes" ifyour child copies four ofthe letters and you can read them. Mark "sometimes" if your child copies two or three letters and you can read them.)

Yes Sometimes Not Yet

6. Print your child's first name. Can your child copy the letters? The letters may be large, backward, or reversed. (Mark "sometimes" if your child copies about half of the letters.)

Yes Sometimes Not Yet

FINE MOTOR TOTAL

PROBLEM SOLVING

1. When asked, "Which circle is smallest?" does your child point to the smallest circle? (Ask this question without providing help by pointing, gesturing, or looking at the smallest circle.)

Yes Sometimes Not Yet

2. When shown objects and asked, "What color is this?" does your child name five different colors like red, blue, yellow, orange, black, white, or pink? (Mark "yes" only if your child answers the question correctly using five colors.)

Yes Sometimes Not Yet

3. Does your child count up to 15 without making mistakes? If so, mark "yes." If your child counts to 12 without making mistakes, mark "sometimes."

Yes Sometimes Not Yet

4. Does your child finish the following sentences using a word that means the opposite of the word that is italicized? For example: "A rock is hard, and a pillow is soft."

Yes Sometimes Not Yet

Please write your child's responses below:

A cow is big, and a mouse is

Ice is cold, and fire is

We see stars at night, and we see the sun during the

When I throw the ball up, it comes

(Mark "yes" if he finishes three of four sentences correctly. Mark "sometimes" if he finishes two of four sentences correctly.)

5. Does your child know the names of numbers? (Mark "yes" ifshe identifies the three numbers below. Mark "sometimes” if she identifies two numbers.)

Yes Sometimes Not Yet

6. Does your child name at least four letters in her name? Point to the letters and ask, "What letter is this?" (Point to the letters out of order.)

Yes Sometimes Not Yet

PROBLEM SOLVING TOTAL

PERSONAL-SOCIAL

1. Can your child serve himself, taking food from one container to another, using utensils? For example, does your child use a large spoon to scoop applesauce from a jar into a bowl?

Yes Sometimes Not Yet

2. Does your child wash her hands and face using soap and water and dry off with a towel without help?

Yes Sometimes Not Yet

3. Does your child tell you at least four of the following? Please mark the items your child knows.

Yes Sometimes Not Yet

a. First name

b. Age

c. City she lives in

d. Last name

e. Boy or girl

f. Telephone number

4. Does your child dress and undress himself, including buttoning medium-size buttons and zipping front zippers?

Yes Sometimes Not Yet

5. Does your child use the toilet by herself? (She goes to the bathroom, sits on the toilet, wipes, and flushes.) Mark "yes" even if she does this after you remind her

Yes Sometimes Not Yet

6. Does your child usually take turns and share with other children?

Yes Sometimes Not Yet

PERSONAL-SOCIAL TOTAL

OVERALL

Parents and providers may use the space below for additional comments.

1. Do you think your child hears well? If no, explain;

Yes No

2. Do you think your child talks like other children her age? If no, explain:

Yes No

3. Can you understand most of what your child says? If no, explain:

Yes No

4. Can other people understand most of what your child says? If no, explain:

Yes No

5. Do you think your child walks, runs, and climbs like other children his age? If no, explain:

Yes No

6. Does either parent have a family history of childhood deafness or hearing impairment? If yes, explain:

Yes No

7. Do you have any concerns about your child's vision? If yes, explain:

Yes No

8. Has your child had any medical problems in the last several months? If yes, explain:

Yes No

9. Do you have any concerns about your child's behavior? If yes, explain:

Yes No

10. Does anything about your child worry you? If yes, explain:

Yes No

6 Month ASQ-3 Information Summary

Child's name

Date ASQ completed

Child's ID #

Date of Birth

Administering program/provider

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.

AREA

CUT-OFF

TOTAL SCORE

Communication

33.19

Gross Motor

31.28

Fine Motor

26.54

Problem Solving

29.99

Personal-Social

39.07

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

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

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.

4. FOLLOW-UP ACTION TAKEN: Check ail 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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