Along with the forms below, please bring a copy of your child's birth certificate and immunization records to their screening appointment.
Forms to be completed for Screenings:
1. Hearing and Vision Worksheet
2. Screening Registration Form
3. Child Health and Developmental History (3-5 years)
4. Early Childhood Screening Consent
5. Early Childhood Screening Release of Information
6. ISD#181 Enrollment Form
7. MN Language Survey
8. Ethnic and Racial Demographic Designation Form
9. ASQ:SE-2
Please choose the ASQ form below appropriate for your child's age on their screening day:
ASQ:SE-2 for 2 yrs, 9 mo-3 yrs, 5 mo
ASQ:SE-2 for 3 yrs, 6 mo-4 yrs, 5 mo
ASQ:SE-2 for 4 yrs, 6 mos- 5 yrs, 5 mo
Paper forms can be printed and brought to the appointment or emailed to [email protected]
Spanish/Español: Recuerde imprimir y completar el paquete de registro de la prueba en español para la cita de su hijo.
Vietnamese/tiếng Việt: Xin vui lòng nhớ in và hoàn thành hồ sơ đăng ký kiểm tra bằng tiếng Việt cho cuộc hẹn của con bạn.
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