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

Please select the Kentucky county where the center is located

Center Phone Number

Phone

Additional Phone Numbers and Extensions

Center Email

Center Website

How many children are enrolled?

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?

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

Is there a secondary contact you would like to provide?

Yes

Monitoring and Screening Information

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

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

Yes

Does your center currently use a screening tool?

Yes

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

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

Additional Information

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

Send me a copy of my responses

Report Abuse

ASQ® Online Developmental Screens Information Request

Child Care Center Information

Contact Information

Monitoring and Screening Information

Additional Information

ASQ® Online Developmental Screens
Information Request