Asq 14 Month Questionnaire – Fill Out and Use This PDF

The Asq 14 Month Questionnaire is a tool that can be used to assess the strengths and weaknesses of your organization. The questionnaire comprises two main parts – an analysis of an individual's job performance, and also answers to questions related to organizational performance.

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Asq 14 Month Questionnaire PDF Details

As parents, we want to ensure that our children are meeting key developmental milestones. The American Academy of Pediatrics (AAP) has created a questionnaire to help parents track their child's development during the first 14 months of life. The Asq 14 Month Questionnaire can be used to monitor your child's progress in five major categories: physical development, language skills, problem solving abilities, social-emotional skills, and curiosity and exploratory behavior. By tracking your child's progress with this questionnaire, you can identify any potential delays and seek assistance from a healthcare provider if necessary.

Below, you'll find a number of details about asq 14 month questionnaire PDF. There, you'll get the information about the form you intend to fill out, including the estimated time for you to fill it out and also other data.

Question	Answer
Form Name	Asq 14 Month Questionnaire
Form Length	7 pages
Fillable?	No
Fillable fields	0
Avg. time to fill out	1 min 45 sec
Other names	ages and stages 14 months, asq 14month, 14 month asq 3, asq 14 month

Form Preview Example

Ages & Stages

Questionnaires®

14 13 months 0 days through 14 months 30 days

Month Questionnaire

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

Date ASQ completed:

Baby’s information

	Middle
Baby’s first name:	initial:	Baby’s last name:
		If baby was born 3	Baby’s gender:
		or more weeks	Male	Female
		prematurely, # of	Male	Female
		prematurely, # of
Baby’s date of birth:		weeks premature:

Person filling out questionnaire

	Middle	Last name:
First name:	initial:	Last name:
		Relationship to baby:
		Parent	Guardian	Teacher	Child care
		Parent	Guardian	Teacher	provider
					provider
Street address:		Grandparent	Foster	Other:
		or other	parent	Other:
		or other	parent
		relative

	State/	ZIP/
City:	Province:	Postal code:

	Home	Other
	telephone	telephone
Country:	number:	number:

E-mail address:

Names of people assisting in questionnaire completion:

Program Information

	Baby ID #:	Age at administration in months and days:

	Program ID #:	If premature, adjusted age in months and days:

	Program name:


P101140100		Ages & Stages Questionnaires®, Third Edition (ASQ-3™), Squires & Bricker
P101140100		© 2009 Paul H. Brookes Publishing Co. All rights reserved.

14 Month Questionnaire

13 months 0 days through 14 months 30 days

On the following pages are questions about activities babies may do. Your baby may have already done some of the activities described here, and there may be some your baby has not begun doing yet. For each item, please fill in the circle that indi- cates whether your baby is doing the activity regularly, sometimes, or not yet.

Important Points to Remember:

✓

❑ Try each activity with your baby before marking a response.

✓

❑ Make completing this questionnaire a game that is fun for you and your baby.

✓

❑ Make sure your baby is rested and fed.

✓

❑ Please return this questionnaire by _______________.

Notes:

____________________________________________

At this age, many toddlers may not be cooperative when asked to do things. 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. If your baby can do the activity but refuses, mark “yes” for the item.

COMMUNICATION

YES

SOMETIMES

NOT YET

1. 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.)

2. When your baby wants something, does she tell you by pointing to it?

3. Does your baby shake his head when he means “no” or “yes”?

4. Does your baby point to, pat, or try to pick up pictures in a book?

5. Does your baby say four or more words in addition to “Mama” and “Dada”?

6. When you ask her to, does your baby go into another room to find a fa- miliar toy or object? (You might ask, “Where is your ball?” or say, “Bring me your coat,” or “Go get your blanket.”)

COMMUNICATION TOTAL

GROSS MOTOR

YES

SOMETIMES

NOT YET

1. 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.)

2. When you hold one hand just to balance her, does your baby take several steps forward? (If your baby already walks alone, mark “yes” for this item.)

page 2 of 6

E101140200	Ages & Stages Questionnaires®, Third Edition (ASQ-3™), Squires & Bricker
	© 2009 Paul H. Brookes Publishing Co. All rights reserved.

14 Month Questionnaire page 3 of 6

GROSS MOTOR (continued)

YES

SOMETIMESNOT YET

3. Does your baby stand up in the middle of the floor by himself and take several steps forward?

4. Does your baby climb onto furniture or other large objects, such as large climbing blocks?

5. Does your baby bend over or squat to pick up an object from the floor and then stand up again without any support?

6. Does your baby move around by walking, rather than by crawling on his hands and knees?

GROSS MOTOR TOTAL

FINE MOTOR

YES

SOMETIMES

NOT YET

1. Without resting her arm or hand on the table, does your baby pick up a crumb or Cheerio with the tips of her thumb and a finger?

2. Does your baby throw a small ball with a forward arm mo- tion? (If he simply drops the ball, mark “not yet” for this item.)

3. Does your baby help turn the pages of a book? (You may lift a page for her to grasp.)

4. Does your baby stack a small block or toy on top of another one?

(You could also use spools of thread, small boxes, or toys that are about 1 inch in size.)

5. Does your baby make a mark on the paper with the tip

of a crayon (or pencil or pen) when trying to draw?

6. Does your baby stack three small blocks or toys on top of each other by herself?

FINE MOTOR TOTAL

E101140300	Ages & Stages Questionnaires®, Third Edition (ASQ-3™), Squires & Bricker
	© 2009 Paul H. Brookes Publishing Co. All rights reserved.

14 Month Questionnaire page 4 of 6

PROBLEM SOLVING

YES

SOMETIMES

NOT YET

1.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.)

2.Does your baby drop two small toys, one after the other, into a container like a bowl or box? (You may show

her how to do it.)

3.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.)

4.Can your baby drop a crumb or Cheerio into a small, clear bottle (such as a plastic soda-pop bottle or baby bottle)?

5.Does your baby drop several small toys, one after another, into a con- tainer like a bowl or box? (You may show her how to do it.)

6.After you have shown your baby how, does he try to get a small toy that is slightly out of reach by using a spoon, stick, or similar tool?

PROBLEM SOLVING TOTAL

*If Problem Solving Item 2 is marked “yes” or “sometimes,” mark Problem Solving Item 1 as “yes.”

PERSONAL-SOCIAL

YES

SOMETIMES

NOT YET

1. When you dress your baby, does she lift her foot for her shoe, sock, or pant leg?

2. Does your baby roll or throw a ball back to you so that you can return it to him?

3. Does your baby play with a doll or stuffed animal by hugging it?

4. Does your baby feed herself with a spoon, even though she may spill some food?

5. Does your baby help undress himself by taking off clothes like socks, hat, shoes, or mittens?

6. Does your baby get your attention or try to show you something by pulling on your hand or clothes?

PERSONAL-SOCIAL TOTAL

E101140400	Ages & Stages Questionnaires®, Third Edition (ASQ-3™), Squires & Bricker
	© 2009 Paul H. Brookes Publishing Co. All rights reserved.

14 Month Questionnaire page 5 of 6

OVERALL

Parents and providers may use the space below for additional comments.

1. Does your baby use both hands and both legs equally well? If no, explain:

YES

2. Does your baby play with sounds or seem to make words? If no, explain:

YES

3. When your baby is standing, are her feet flat on the surface most of the time?	YES	NO
If no, explain:

4. Do you have concerns that your baby is too quiet or does not make sounds like	YES	NO
other babies do? If yes, explain:

5. Does either parent have a family history of childhood deafness or hearing	YES	NO
impairment? If yes, explain:

E101140500	Ages & Stages Questionnaires®, Third Edition (ASQ-3™), Squires & Bricker
	© 2009 Paul H. Brookes Publishing Co. All rights reserved.

14 Month Questionnaire page 6 of 6

OVERALL (continued)
6. Do you have concerns about your baby’s vision? If yes, explain:	YES	NO

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

YES

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

YES

9. Does anything about your baby worry you? If yes, explain:

YES

E101140600	Ages & Stages Questionnaires®, Third Edition (ASQ-3™), Squires & Bricker
	© 2009 Paul H. Brookes Publishing Co. All rights reserved.

14 Month ASQ-3 Information Summary	13 months 0 days through
	14 months 30 days

Baby’s name: ______________________________________________________

Baby’s ID #: ______________________________________________________

Administering program/provider:

Date ASQ completed: __________________________________________

Date of birth: ______________________________________________

Was age adjusted for prematurity
when selecting questionnaire?	Yes	No

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.

	Total	0	5	10	15	20	25	30	35	40	45	50	55	60
Area	Cutoff Score	0	5	10	15	20	25	30	35	40	45	50	55	60
Communication	17.40
Gross Motor	25.80
Fine Motor	23.06
Problem Solving	22.56
Personal-Social	23.18

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

1.	Uses both hands and both legs equally well?	Yes	NO	6.	Concerns about vision?	YES	No
	Comments:				Comments:
2.	Plays with sounds or seems to make words?	Yes	NO	7.	Any medical problems?	YES	No
	Comments:				Comments:
3.	Feet are flat on the surface most of the time?	Yes	NO	8.	Concerns about behavior?	YES	No
	Comments:				Comments:
4.	Concerns about not making sounds?	YES	No	9.	Other concerns?	YES	No
	Comments:				Comments:
5.	Family history of hearing impairment?	YES	No
	Comments:

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 baby’s total score is in the If the baby’s total score is in the If the baby’s total score is in the

area, it is above the cutoff, and the baby’s development appears to be on schedule.

area, it is close to the cutoff. Provide learning activities and monitor.

area, it is below the cutoff. Further assessment with a professional may be needed.

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).

Communication

Gross Motor

Fine Motor

Problem Solving

Personal-Social

P101140700	Ages & Stages Questionnaires®, Third Edition (ASQ-3™), Squires & Bricker
	© 2009 Paul H. Brookes Publishing Co. All rights reserved.

How to Edit Asq 14 Month Questionnaire Online for Free

We've used the efforts of the best computer programmers to design the PDF editor you are about to use. Our software will permit you to prepare the ages and stages questionnaire 14 months form effortlessly and don’t waste time. All you need to undertake is comply with these particular straightforward guidelines.

Step 1: Click the orange "Get Form Now" button on this web page.

Step 2: Now, you are on the file editing page. You may add content, edit existing information, highlight certain words or phrases, put crosses or checks, insert images, sign the form, erase needless fields, etc.

You should enter the next details to be able to prepare the file:

Provide the requested information in First name, Street address, City, Country, Email address, Names of people assisting in, Program Information, Baby ID, Program ID, Middle initial, Last name, Relationship to baby, Parent, Guardian, and Teacher segment.

14 mo asq First name, Street address, City, Country, Email address, Names of people assisting in, Program Information, Baby ID, Program ID, Middle initial, Last name, Relationship to baby, Parent, Guardian, and Teacher fields to complete

You should point out the fundamental particulars from the Program name, and Ages Stages Questionnaires Third area.

In the paragraph Important Points to Remember, Try each activity with your baby, Make completing this questionnaire, Notes, Make sure your baby is rested and, Please return this questionnaire, At this age many toddlers may not, COMMUNICATION, YES, SOMETIMES, NOT YET, Does your baby say three words, Baba A word is a sound or sounds, When your baby wants something, and Does your baby shake his head, include the rights and responsibilities of the sides.

14 mo asq Important Points to Remember, Try each activity with your baby, Make completing this questionnaire, Notes, Make sure your baby is rested and, Please return this questionnaire, At this age many toddlers may not, COMMUNICATION, YES, SOMETIMES, NOT YET, Does your baby say three words, Baba A word is a sound or sounds, When your baby wants something, and Does your baby shake his head fields to insert

Fill in the template by checking the next fields: Dada, When you ask her to does your, miliar toy or object You might ask, GROSS MOTOR, YES, SOMETIMES, NOT YET, COMMUNICATION TOTAL, If you hold both hands just to, When you hold one hand just to, baby take several steps forward If, Ages Stages Questionnaires Third, and page of.

Step 3: Click the Done button to assure that your completed file is available to be exported to any kind of device you want or mailed to an email you specify.

Step 4: It is better to maintain duplicates of the form. You can rest assured that we won't publish or see your data.

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