Results of Screening Questionnaire

Lisa Freck

Child’s name: James (Jay) Parents: S.F. & J. F.

Child’s Date of Birth: November 2018 Date of Screening: 2/23/2020

Child’s Chronological Age: 15 months Location of Service: Family’s home

Background information: Family of 4 with one on the way. Older sister (6 yr. old) is mom’s
daughter from another marriage but was adopted by mom’s husband. Jay is 15 months old. Mom
and Dad both work full time. Sister goes to school in Medina City Schools. Jay goes to mom’s
sister’s house when she works.

Current Assessment: I used the ASQ-3 assessment for children ages 15 months 0 days – 16
months 30 days. It was administered through family interview and some observation. The ASQ-3
assessment looks at the five major development domains of the child including communication,
gross motor, fine motor, problem solving, and personal-social skills. It tells us whether or not
your child can do certain skills in each domain and scores them based on a cut-off score for a
typically developing child. The child’s scores will be compared to the cut-off score and will
determine which areas (if any) the child is struggling in. This can help determine whether or not
further assessment or evaluation needs to be done.

Summary of Scores

Child’s Scores ASQ-3 Cutoff Scores

Communication 15 16.81

Gross Motor 10 37.91

Fine Motor 30 31.98

Problem Solving 25 30.51

Personal-social 45 26.43

Domains with scores that indicate the child’s development is on schedule: Domains in which
the child scored above the cut-off were personal-social. This means that this child on track for
their personal-social skills.

Domains with scores that indicate concerns or in the monitoring zone: Domains in which the
child’s scores were in the monitoring zone or below were communication, gross motor, fine
motor, and problem solving. This means that this child is only doing some of the said activities
in each of these domains, leaving them in the concern or monitoring area requiring further
assessment or evaluation at another time. This could be due to the child’s age considering he is
only 15 months old which is on the younger end of the age group for this assessment.

Reflection: I felt comfortable doing this assessment because it was simple and straightforward. It
was something that didn’t need a lot of setting up to see if the child can do this or that. To me, it
felt more like an assessment for mom and dad to see where their child is at developmentally, in
each of these domains. It gives them an idea of what areas they could work on with their child.
As the assessor, I could help them out if they have any questions and give them some ideas of
different types of activities, they can do to support their child in the struggling domains.