Form 11.1 Survey

OMB #: 0925-0593

OMB Expiration Date: 8/31/2014

2M Ages & Stages-3 (ASQ-3™) SAQ, Phase 2g

OMB Specification

2M Ages & Stages-3 (ASQ-3™) SAQ

Event Category:	Time-Based
Event:	3M
Administration:	N/A
Instrument Target:	Child
Instrument Respondent:	Primary Caregiver
Domain:	Neuro-Psychosocial
Document Category:	Scored Assessment
Mode (for this instrument*):	In-Person, PAPI; Phone, PAPI
OMB Approved Modes:	In-Person, PAPI; Phone, PAPI
Method:	Self-Administered
Estimated Administration Time:	13 minutes
Multiple Child/Sibling Considerations:	Per Child
Special Considerations:	N/A
Version:	1.0
MDES Release:	4.0
Publisher:	Paul H. Brookes Publishing Co.
NCS Contact:	Carol Andreassen Westat 301-251-1500

*This instrument is OMB-approved for multi-mode administration but this version of the instrument is designed for administration in this/these mode(s) only.

Ages & Stages Questionnaires®, Third Edition (ASQ-3™), Squires & Bricker© 2009 Paul H. Brookes Publishing Co. All Rights reserved.Ages & Stages Questionnaires® is a registered trademark and ASQ-3™ is a trademark of Paul H. Brookes Publishing Co.

The Ages & Stages Questionnaires®, Third Edition (ASQ-3™) is a series of 21 age-specific questionnaires and scoring sheets designed to screen a child’s skills in five developmental areas: fine motor, gross motor, problem solving, communication, and personal-social. The instrument covers ages 1 month to 66 months.

The ASQ-3™ is available in English and Spanish and is a proprietary questionnaire.

Public reporting burden for this collection of information is estimated to average 13 minutes per response, including the time for reviewing instructions, searching existing data sources, gathering and maintaining the data needed, and completing and reviewing the collection of information. An agency may not conduct or sponsor, and a person is not required to respond to, a collection of information unless it displays a currently valid OMB control number. Send comments regarding this burden estimate or any other aspect of this collection of information, including suggestions for reducing this burden, to: NIH, Project Clearance Branch, 6705 Rockledge Drive, MSC 7974, Bethesda, MD 20892-7974, ATTN: PRA (0925-0593*). Do not return the completed form to this address.