14 Month Questionnaire (ASQ-3) at a glance
What it is: The Ages & Stages Questionnaires 14 Month Questionnaire has questions about activities babies may do, for 13 months 0 days through 14 months 30 days.
A filled-in 14 Month Questionnaire (ASQ-3) example: a child care provider fills out the first page
How to fill out 14 Month Questionnaire (ASQ-3), box by box
Baby's information
Under Baby's information, enter Baby's first name, Baby's last name and Middle initial.
Mark Baby's gender: Male or Female.
Enter Baby's date of birth.
If baby was born 3 or more weeks prematurely, enter # of weeks premature.
Person filling out questionnaire
Under Person filling out questionnaire, enter First name, Last name and Middle initial.
For Relationship to baby, mark Parent, Guardian, Grandparent or other relative, Foster parent, Teacher, Child care provider or Other.
Enter Street address, City, State/ Province, ZIP/ Postal code and Country.
Enter Home telephone number, Other telephone number and E-mail address.
Enter Names of people assisting in questionnaire completion.
Program Information
Under Program Information, enter Age at administration in months and days, Baby ID #, Program ID # and Program name.
If premature, enter adjusted age in months and days.
OVERALL
OVERALL: Parents and providers may use the space for additional comments.
Mark YES or NO for “Does your baby use both hands and both legs equally well?” If no, explain.
Mark YES or NO for “Does your baby play with sounds or seem to make words?” If no, explain.
Mark YES or NO for “When your baby is standing, are her feet flat on the surface most of the time?” If no, explain.
Mark YES or NO for “Do you have concerns that your baby is too quiet or does not make sounds like other babies do?” If yes, explain.
Mark YES or NO for “Does either parent have a family history of childhood deafness or hearing impairment?” If yes, explain.
OVERALL (continued)
OVERALL (continued): Mark YES or NO for “Do you have concerns about your baby's vision?” If yes, explain.
Mark YES or NO for “Has your baby had any medical problems in the last several months?” If yes, explain.
Mark YES or NO for “Do you have any concerns about your baby's behavior?” If yes, explain.
Mark YES or NO for “Does anything about your baby worry you?” If yes, explain.
Month ASQ-3 Information Summary
Under Month ASQ-3 Information Summary, enter Baby's name, Date ASQ completed, Baby's ID #, Date of birth and Administering program/provider, and mark Yes or No for Was age adjusted for prematurity when selecting questionnaire?
More rules for 14 Month Questionnaire (ASQ-3)
For each item, fill in the circle that indicates whether your baby is doing the activity regularly, sometimes, or not yet.
If your baby can do the activity but refuses, mark “yes” for the item.
Important Points to Remember: Try each activity with your baby before marking a response.
You may need to try the following activities with your baby more than one time.
If possible, try the activities when your baby is cooperative.
Does your baby say three words, such as “Mama,” “Dada,” and “Baba”? (A “word” is a sound or sounds your baby says consistently to mean someone or something.)
If you hold both hands just to balance your baby, does he take several steps without tripping or falling? (If your baby already walks alone, mark “yes” for this item.)
Does your baby throw a small ball with a forward arm motion? (If he simply drops the ball, mark “not yet” for this item.)
If you put a small toy into a bowl or box, does your baby copy you by putting in a toy, although he may not let go of it? (If he already lets go of the toy into a bowl or box, mark “yes” for this item.)
After you scribble back and forth on paper with a crayon (or a pencil or pen), does your baby copy you by scribbling? (If he already scribbles on his own, mark “yes” for this item.)
If Problem Solving Item 2 is marked “yes” or “sometimes,” mark Problem Solving Item 1 as “yes.”
Score and transfer totals to chart: 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, transfer the total scores, and fill in the circles corresponding with the total scores.
Transfer overall responses: Bolded uppercase responses require follow-up.
You must consider total area scores, overall responses, and other considerations, such as opportunities to practice skills, to determine appropriate follow-up.
Under FOLLOW-UP ACTION TAKEN, check all that apply: 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, or No further action taken at this time.
Common questions about 14 Month Questionnaire (ASQ-3)
Is there a deadline?
Please return this questionnaire by _______________.
Sources
[1] 14 Month Questionnaire, Ages & Stages Questionnaires, Third Edition (ASQ-3), as published by TRICARE (raymond-bliss.tricare.mil) (the Official source link on this page).
