TAIP SECTION 2

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Person filling out questionnaire

Child’s information

Relationship to child:

Parent

Street address:

Names of people assisting in questionnaire completion:

Grandparent or other relative

Guardian

Foster parent

Teacher Child care provider

Other:

PROGRAM INFORMATION Child ID #:

Program name:

Program ID #:

Ages & Stages Questionnaires®

Month Questionnaire 45 months 0 days through 50 months 30 days

Please provide the following information. Use black or blue ink only and print legibly when completing this form.

Child’s first name: Child’s last name:

Child’s date of birth:

First name: Last name: Middle initial:

City:

Home telephone number:

State/Province: ZIP/Postal code:

Other telephone number:

E-mail address:

Child’s gender:

Male Female

Middle initial:

Country:

M M D D Y Y Y Y

Date ASQ completed: M M D D Y Y Y Y

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Month Questionnaire48 45 months 0 days through 50 months 30 days

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:

____________________________________________

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.

COMMUNICATION

1. Does your child name at least three items from a common category? For example, if you say to your child, “Tell me some things that you can eat,” does your child answer with something like “cookies, eggs, and cereal”? Or if you say, “Tell me the names of some animals,” does your child answer with something like “cow, dog, and elephant”?

2. Does your child answer the following questions? (Mark “sometimes” if your child answers only one question.)

“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:

3. Does your child tell you at least two things about common objects? For example, if you say to your child, “Tell me about your ball,” does she say something like, “It’s round. I throw it. It’s big”?

4. Does your child use endings of words, such as “-s,” “-ed,” and “-ing”? For example, does your child say things like, “I see two cats,” “I am playing,” or “I kicked the ball”?

YES SOMETIMES NOT YET

COMMUNICATION (continued)

5. Without your giving help by pointing or repeating, does your child fol- low 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.”

6. Does your child use all of the words in a sentence (for example, “a,” “the,” “am,” “is,” and “are”) to make complete sentences, such as “I am going to the park,” or “Is there a toy to play with?” or “Are you coming, too?”

GROSS MOTOR

1. 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.)

2. Does your child climb the rungs of a ladder of a playground slide and slide down without help?

3. 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.”)

4. Does your child hop up and down on either the right or left foot at least one time without losing her balance or falling?

5. Does your child jump forward a distance of 20 inches from a standing position, starting with his feet together?

6. 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.)

FINE MOTOR

1. Does your child put together a five- to seven-piece interlocking puzzle? (If one is not available, take a full-page picture from a magazine or catalog and cut it into six pieces. Does your child put it back together correctly?)

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YES SOMETIMES NOT YET

COMMUNICATION TOTAL

YES SOMETIMES NOT YET

GROSS MOTOR TOTAL

YES SOMETIMES NOT YET

FINE MOTOR (continued)

2. Using child-safe scissors, does your child cut a 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.)

3. Using the shapes below to look at, does your child copy at least three shapes onto a large piece of paper using a pencil, crayon, or pen, with- out tracing? (Your child’s drawings should look similar to the design of the shapes below, but they may be different in size.)

4. Does your child unbutton one or more buttons? (Your child may use his own clothing or a doll’s clothing.)

5. Does your child draw pictures of people that have at least three of the following features: head, eyes, nose, mouth, neck, hair, trunk, arms, hands, legs, or feet?

6. Does your child color mostly within the lines in a coloring book or within the lines of a 2-inch circle that you draw? (Your child should not go more than 1/4 inch outside the lines on most of the picture.)

PROBLEM SOLVING

1. When you say, “Say ‘five eight three,’” does your child repeat just the three numbers in the same order? Do not repeat the numbers. If neces- sary, try another series of numbers and say, “Say ‘six nine two.’” (Your child must repeat just one series of three numbers to answer “yes” to this question.)

2. When asked, “Which circle is the smallest?” does your child point to the smallest circle? (Ask this question without providing help by point- ing, gesturing, or looking at the smallest circle.)

3. Without your giving help by pointing, does your child follow three dif- ferent directions using the words “under,” “between,” and “middle”? For example, ask your child to put the shoe “under the couch.” Then ask her to put the ball “between the chairs” and the book “in the middle of the table.”

4. 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.)

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YES SOMETIMES NOT YET

FINE MOTOR TOTAL

YES SOMETIMES NOT YET

PROBLEM SOLVING (continued)

5. Does your child dress up and “play-act,” pretending to be someone or something else? For example, your child may dress up in different clothes and pretend to be a mommy, daddy, brother, or sister, or an imaginary animal or figure.

6. If you place five objects in front of your child, can he count them by saying, “one, two, three, four, five,” in order? (Ask this question without providing help by pointing, gesturing, or naming.)

PERSONAL-SOCIAL

1. Does your child serve herself, taking food from one container to an- other using utensils? For example, does your child use a large spoon to scoop applesauce from a jar into a bowl?

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

a. First name d. Last name

b. Age e. Boy or girl

c. City she lives in f. Telephone number

3. Does your child wash his hands using soap and water and dry off with a towel without help?

4. Does your child tell you the names of two or more playmates, not in- cluding brothers and sisters? (Ask this question without providing help by suggesting names of playmates or friends.)

5. Does your child brush her teeth by putting toothpaste on the tooth- brush and brushing all of her teeth without help? (You may still need to check and rebrush your child’s teeth.)

6. Does your child dress or undress himself without help (except for snaps, buttons, and zippers)?

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YES SOMETIMES NOT YET

PROBLEM SOLVING TOTAL

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

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OVERALL (continued)

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

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

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

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

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

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

YES NO

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OVERALL (continued)

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

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

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

YES NO

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 child’s total score is in the area, it is above the cutoff, and the child’s development appears to be on schedule. If the child’s total score is in the area, it is close to the cutoff. Provide learning activities and monitor. If the child’s total score is in the area, it is below the cutoff. Further assessment with a professional may be needed.

Child’s name: ________________________________________________________

Child’s ID #: ______________________________________________________

Administering program/provider:

Date ASQ completed: __________________________________________

Date of birth: ______________________________________________

Month ASQ-3 Information Summary48 45 months 0 days through 50 months 30 days

Communication

Gross Motor

Fine Motor

Problem Solving

Personal-Social

1 2 3 4 5 6

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

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.

Communication

Gross Motor

Fine Motor

Problem Solving

Personal-Social

0 5 10 15 20 25 30 35 40 45 50 55 60 Total

Area Cutoff Score

30.72

32.78

15.81

31.30

26.60

4. FOLLOW-UP ACTION TAKEN: Check all 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).