ASQ® Online Developmental Screens Information Request

ASQ® Online Developmental Screens

Information Request

Thank you for your interest in the Ages and Stages Questionnaires® (ASQ®) online developmental screening tools. Please complete the form below to get started on embedding developmental screening into your childcare program.

This form requires the following information:

Child Care Center Information
Contact Information
Monitoring and Screening Information
Additional Information

Once your referral is submitted, a member of our team will process the information and contact you with next steps.

If you require additional support, please contact Sally Dannenberg at sally.dannenberg@uky.edu or 859-218-3669.

Child Care Center Information

Please provide information for the participating Child Care Center

Please select the option that best describes your center*

Family Care Center

Child Care Center

Other

Center Name*

If there are multiple locations, please specify location name

For example, J-Town and Fern Valley are Youth Kids Academy's locations.

Center Address*

Is your center mailing address different than above?*

Yes

Preferred Center Mailing Address*

Please select the Kentucky county where the center is located*

Select

Center Phone Number*

Phone

Additional Phone Numbers and Extensions

Center Email*

Center Website

How many children are enrolled?*

Select

Please provide any additional information on children enrolled or served at your center

What age groups does the center serve? Select all that apply:*

Infant (0-24 months)

Toddler (24 months to 3 years old)

Young Children (3 years old to 5 years old)

School Aged Children (5 years old to 12 years old)

How many employees does the center employ?

Select

Contact Information

Please provide information for your Child Care Center's primary contact. You will have the option to provide up to three contacts.

Name*

Title*

Phone Number*

Phone

Additional Phone Numbers and Extensions

Email*

Is there a secondary contact you would like to provide?*

Yes

Secondary Contact Information

Name*

Title

Phone Number

Phone

Additional Phone Numbers and Extensions

Email*

Monitoring and Screening Information

How did your center hear about the "Learn the Signs. Act Early." and Help Me Grow Kentucky Program?*

Other

Does your center currently use the “Learn the Signs. Act Early.” Materials?*

Yes

Please provide name and email address information of your center's Child Care Aware Coaches, if known.

If more than one, include multiple names and contact info in the provided space.

Need to look up your Child Care Aware Coach? Click here.

Does your center currently use a screening tool?*

Yes

What screening tool does your center use? Select all that apply.*

ASQ®-3

ASQ®-SE

Brigance

Other

Is your center familiar with ASQ®?*

Ages & Stages Questionnaires® is a developmental screening tool designed for use by early educators and health care professionals. Learn more

Yes

Somewhat

Other

Does your center discuss options for referral to early intervention with the parent/caregiver?*

Yes

Are you interested in receiving our free electronic CHAMPIONS newsletter that provides updates on current Early Childhood initiatives?*

Yes

Please provide the email you would like to receive the CHAMPIONS newsletter

Additional Information

Please provide any additional information to help us to best support you

Send me a copy of my responses

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