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Questionnaire

1 month 0 days through 2 months 30 days

BASOSE' ¿I

Questionnaires

Date ASQ:SE-2 completed:

Baby's information

Baby's first name:

Baby's date of birth:

Baby's gender: Male (^) Female

Baby's middle initial:

Baby's last name:

If baby was born 3 or more weeks premature, please enter the number of weeks:

Person filling out questionnaire

First name: Middle initial: Last name:

Street address:

City: State/ province: ZIP/postal code:
Country:

Home Other

telephone telephone

number: number:

E-mail address:

Relationship to baby:

Parent

Grandparent/ other relative

Guardian

Foster parent

Q Teacher Q Other:

Q Child care

provider

People assisting in questionnaire completion:

Program information (For program use only.)
Baby's ID #: Age at administration in months and days:
Program ID #: If premature, adjusted age in months and days:
Program name: ---------------------------

P201020000

Ages & Stages Questionnaires®: Social-Emotional. Second Edition (ASQ:SE-2™), Squires, Bricker, & Twombly.

© 2015 Paul H. Brookes Publishing Co., Inc. All rights reserved.

( 2 Month Questionnaire

Questions about behaviors babies may have are listed on the following pages. Please read each question carefully and check the box [~7f that best describes your baby's behavior. Also, check the circle if the behavior is a concern.

Important Points to Remember:

Answer questions based on what you know about your Q baby's behavior, Q

Answer questions based on your baby's usual behavior,

not behavior when your baby is sick, very tired, or hungry. Q

Caregivers who know the baby well and spend more than

15-20 hours per week with the baby should complete ASQ:SE-2.

Please return this questionnaire by:

If you have any questions or concerns about your baby or about this questionnaire, contact:

Thank you and please look forward to filling out another

ASQ:SE-2 in months.

  1. When upset, can your baby calm down within a half hour?
  2. Does your baby like to be picked up and held?
  3. Does your baby stiffen and arch her back when picked up?
  4. When you talk to your baby, does he look at you and seem to listen?
  5. Does your baby let you know when she is hungry, tired, or uncomfortable? For example, does she fuss or cry?
  6. When awake, does your baby seem to enjoy watching or listening to people? For example, does he turn his head to look at someone talking?
  7. Is your baby able to calm herself down (for example, by sucking her hand or pacifier)?

8. Does your baby cry for long periods of time?

OFTEN OR ! SOME- ALWAYS ; TIMES

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P201020100

Ages & Stages Questionnaires®: Social-Emotional, Second Edition (ASQ:SE-2™), Squires, Bricker, & Twombly.

© 2015 Paul H. Brookes Publishing Co., inc. All rights reserved.

page I of 3

2 Month Questionnaire

Basq^se^

Check the box |~i/f that best describes your child's behavior.

Also, check the circle if the behavior is a concern.

  • --------------------------------- ;. — -—-----------^e iEGK ir OFTEN OR ; SOME- ; RARELY OR THIS IS A ALWAYS ; TIMES ; NEVER CONCERN
  • Is your baby's body relaxed?
  • Does your baby have trouble sucking from a breast or bottle?
  • Does it take longer than 30 minutes to feed your baby?
  • Do you and your baby enjoy feeding times together?
  • Does your baby have any eating problems, such as gagging, vomiting, or? (Please describe.)
  • During the day, does your baby stay awake for an hour or longer at one time?
  • Does your baby sleep at least 10 hours in a 24-hour period?
  • Has anyone shared concerns about your baby's behaviors?
  • "sometimes" or "often or always," please explain:

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P201020200

Ages & Stages Questionnaires®: Social-Emotional, Second Edition (ASQ:5£-2™), Squires, Bricker, & Twombly.

© 2015 Paul H. Brookes Publishing Co., Inc. All rights reserved.

page 2 of 3

2 Month Questionnaire

BasqseI

OVERALL Use the space below for additional comments.

  1. you have concerns about your baby's eating or steeping behaviors? If yes, please explain:
  1. Does anything about your baby worry you? If yes, please explain:

O yes Q NO

  1. What do you enjoy about your baby?

P201020300

Ages & Stages Questionnaires®: Social-Emotional, Second Edition (ASQ:SE-2™), Squires, Bricker, & Twombly.

© 2015 Paul H. Brookes Publishing Co., Inc. All rights reserved.

page 3 of 3

2 Month Information Summary 1 month 0 days through 2 months 30 days

BASQUE-J

Baby's name:

Baby's ID #:

Person who completed ASQ:SE-2:

Administering program/provider:

Date ASQ:SE-2 completed:

Baby's date of birth:

Baby's age/adjusted age in months and days:

Baby's gender: Q Male Q Female

1. ASQ:SE-2 SCORING CHART:

« Score items (Z = 0, V = 5, X= 10, Concern = 5).

  • Transfer the page totals and add them for the total score.
  • Record the baby's total score next to the cutoff.

TO'AL PO'NTS ON PAGE 1

TC'rA'_ PO’NTS ON '-’AGt 2

 _____
Total score
Cutoff Total score

35

„ ___

2. ASQ:SE-2 SCORE INTERPRETATION: Review the approximate location of the baby's total score on the scoring graphic. Then,

check off the area for the score results below.

no or low risk

monitor

The baby's total score is in the □□ area. It is below the cutoff. Social-emotional development appears to be on schedule.

The baby's total score is in the CZZI area. It is close to the cutoff. Review behaviors of concern and monitor.

The baby's total score is in the fæl area. It is above the cutoff. Further assessment with a professional may be needed.

3. OVERALL RESPONSES AND CONCERNS: Record responses and transfer parent/caregiver comments. YES responses require follow-up.

1-16. Any Concerns marked on scored items? YES no Comments:
17. Eating/sleeping concerns? YES no Comments:
18. Other worries? YES no Comments:
  1. FOLLOW-UP REFERRAL CONSIDERATIONS: Mark all as Yes, No, or Unsure (Y, N, U). See pages 98-103 in the ASQ:SE-2 User's Guide.

Setting/time factors (e.g., Is the baby's behavior the same at home as at school?)

Developmental factors (e.g., Is the baby's behavior related to a developmental stage or delay?)

Health factors (e.g., Is the baby's behavior related to health or biological factors?)

Family/cultural factors (e.g., Is the baby's behavior acceptable given the baby's cultural or family context? Have there been any stressful events in the baby's life recently?)

Parent concerns (e.g., Did the parent/caregiver express any concerns about the baby's behavior?)

  1. FOLLOW-UP ACTION: Check all that apply.

Provide activities and rescreen inmonths.

Share results with primary health care provider.

Provide parent education materials.

___, Provide information about available parenting classes or support groups.

Have another caregiver complete ASQ:SE-2. List caregiver here (e.g., grandparent, teacher):

Administer developmental screening (e.g., ASQ-3).

___ Refer to early intervention/early childhood special education.

Refer for social-emotional, behavioral, or mental health evaluation.

Other:.......................................................................................................................................................................................................

P201020400

Ages & Stages Questionnaires®: Social-Emotional, Second Edition (ASQ:SE-2™), Squires, Bricker, & Twombly.

© 2015 Paul H. Brookes Publishing Co., !nc. All rights reserved.