I would like to Import…

Import Data Template

Child and Caregiver Profile Data Template

Caregiver Profile Data Only Template

ASQ-3 Data Template

ASQ:SE Data Templates

Child Profile Data Only

X

Child Profile and one Caregiver Profile

X

Caregiver Profile Only

X

ASQ-3 Screening Data for Existing Child Profiles

X

Child Profile, Caregiver Profile, and ASQ-3 Screening Data

X

ASQ:SE Screening Data for existing Child Profiles

X

Child Profile, Caregiver Profile, and ASQ:SE Screening Data

X

I would like to Export…

Export File

Child Profile Data Only

Caregiver Profile Data Only

Screening Data Only

All

Child Demographics

X

X

Child Profile Custom Fields

X

X

Caregiver Demographics

X

X

X

Caregiver Profile Custom Fields

X

X

X

Child Profile Notes

X

Caregiver Profile Notes

X

ASQ-3 Scores and Cutoffs

X

X

ASQ:SE-2 Scores and Cutoffs

X

X

ASQ-3 Individual Questionnaire Responses

X

X

ASQ:SE-2 Individual Questionnaire Responses

X

X

I would like to Update…

Use this Data Template

Include this Identifier in Data Template

Results

Existing Child and Caregiver Profile

Child and Caregiver Profile

Child ID or Alt. ID

Caregiver ID

Only the Child and Caregiver Profiles will be updated. Any existing notes, screening data, and events will remain.

Existing Child Profile Only

Child and Caregiver Profile

Child ID or Alt. ID

Only the Child Profile data will be updated. Any existing notes, screening data, and events will remain.

Existing Caregiver Profile Only

Caregiver Profile Only

Caregiver ID

Only the Caregiver Profile will be updated.

New ASQ-3 Screening for Existing Child and Caregiver Profile

ASQ-3

Child ID or Alt. ID

Caregiver ID

The newly imported ASQ-3 Screening will be added to the existing Child Profile.

New ASQ-3 Screening for Existing Child and New Caregiver Profile

ASQ-3

Child ID or Alt. ID

The newly imported ASQ-3 Screening will be added to the existing Child Profile, and a new Caregiver Profile will be created.

New ASQ:SE-2 Screening for Existing Child and Caregiver Profile

ASQ:SE-2 Templates

Child ID or Alt. ID

Caregiver ID

The newly imported ASQ:SE-2 Screening will be added to the existing Child Profile.

New ASQ:SE-2 Screening for Existing Child and New Caregiver Profile

ASQ:SE-2 Templates

Child ID or Alt. ID

The newly imported ASQ:SE-2 Screening will be added to the existing Child Profile, and a new Caregiver Profile will be created.

Link New Caregiver Profile to Existing Child Profile

Caregiver Profile

Alt. ID

A new Caregiver Profile will be linked to an existing Child Profile.

Link Existing Caregiver Profile to New Child Profile

Child and Caregiver Profile

Caregiver ID

A Caregiver Profile that currently exists in ASQ Online will be linked to a newly imported Child Profile.

Field Name

Data Type

Required

Special Instructions

Program

Text

N

Child ID

Text

N

Alt. ID

Text

N

Last Name

Text

Y

Middle Name

Text

N

First Name

Text

Y

Status

Text

Y

Options are:

 Active

Archived

DOB

Date

Y

Format: mm/dd/yyyy

Weeks Premature

Number

Y

Adjusted Age

Text

N

Gender

Text

Y

Options are:

Male
Female

Birth Weight

Text

N

Ethnicity

Text

N

Options are:

Caucasian

African American

Hispanic or Latino

Asian

Middle-Eastern

Native American

Hawaiian, Pacific Islander
Other

Unknown

Note: Multiple ethnicities can be entered by separating each option with a semicolon (i.e. Asian; Other)

Address1

Text

Y

Address2

Text

N

Address3

Text

N

City

Text

Y

County/District

Text

N

State/Province

Text

Y

Valid options are full names of states/provinces included in the drop-down menu on the Child Profile.

Zip/Postal code

Text

Y

Country

Text

Y

Valid options are countries included in the drop-down menu on the Child Profile.

Phone

Text

Y

Format: 999-999-9999

Primary home language

Text

N

Options are:

English

Spanish

French

Korean

Chinese

Other

Language(s) spoken in the home

Text

N

  Options are:
English

  Spanish

  French

  Korean

  Chinese

  Other

N/A

Primary Care Physician

Text

N

Clinic/Practice Name

Text

N

Clinic Address1

Text

N

Clinic Address2

Text

N

Clinic Address3

Text

N

Clinic City

Text

N

Clinic State/Province

Text

N

Clinic Zip/Postal Code

Text

N

Clinic Phone

Text

N

Clinic Fax

Text

N

Clinic Email

Text

N

Medical risk factors

Text

N

Options are:

Yes or Y, No or N

Environmental risk factors

Text

N

Options are:

Yes or Y, No or N

Medical conditions

Text

N

Options are:

Yes or Y, No or N

Other agencies involved

Text

N

Caregiver ID

Text

N

Caregiver Prefix*

Text

N

Options are:

Mr.

Mrs.

Ms.

Miss

Dr.

Caregiver First Name*

Text

N

Caregiver Middle Name

Text

N

Caregiver Last Name*

Text

N

Relationship to child*

Text

N

Options are:

Foster parent

Guardian

Grandparent or other relative

Father

Mother

Child care provider

Teacher

Other

Caregiver Phone*

Text

N

Caregiver Alternate Phone

Text

N

Caregiver Email

Text

N

Caregiver Primary Home Language*

Text

N

Options are:

English

Spanish

French

Korean

Chinese

Other

Secondary Home Language*

Text

N

Options are:

English

Spanish

French

Korean

Chinese

Other

N/A

Primary Caregiver*

Text

N

Options are:

Yes

No

Caregiver Address1*

Text

N

Caregiver Address2

Text

N

Caregiver Address3

Text

N

Caregiver City*

Text

N

Caregiver County/District

Text

N

Caregiver State/Province*

Text

N

Valid Options are states/provinces included in the drop-down menu on the Caregiver Profile.

Caregiver Zip/Postal Code*

Text

N

Caregiver Country*

Text

N

Valid Options are states/provinces included in the drop-down menu on the Caregiver Profile.

Field Name

Data Type

Required

Special Instructions

Program

Text

N

Caregiver ID

Text

N

Caregiver Prefix

Text

Y

Options are:

Mr.

Mrs.

Ms.

Miss

Dr.

Caregiver First Name

Text

Y

Caregiver Middle Name

Text

N

Caregiver Last Name

Text

Y

Text

N

To link the Caregiver Profile to an existing Child Profile, enter the Alternate Child ID in this field.

Relationship to Child

Text

Y

Options are:

Foster parent

Guardian

Grandparent or other relative

Father

Mother

Child care provider

Teacher

Other

Caregiver Phone

Text

Y

Caregiver Alternate Phone

Text

N

Caregiver Email

Text

N

Caregiver Primary Home Language

Text

Y

Options are:

English

Spanish

French

Korean

Chinese

Other

Secondary Home Language

Text

Y

Options are:

English

Spanish

French

Korean

Chinese

Other

N/A

Primary Caregiver

Text

Y

Options are:

Yes

No

Caregiver Address1

Text

Y

Caregiver Address2

Text

N

Caregiver Address3

Text

N

Caregiver City*

Text

N

Caregiver County/District

Text

N

Caregiver State/Province

Text

Y

Valid Options are states/provinces included in the drop-down menu on the Caregiver Profile.

Caregiver Zip/Postal Code

Text

Y

Caregiver Country

Text

Y

Valid Options are states/provinces included in the drop-down menu on the Caregiver Profile.

Field Name

Data Type

Required

Special Instructions

Program

Text

N

Child ID

Text

N

Alt. ID

Text

N

Date ASQ Completed

Date

Y

Format: mm/dd/yyyy

Child First Name

Text

Y

Child Middle Initial

Text

N

Child Last Name

Text

T

Child DOB

Date

Y

Format: mm/dd/yyyy

Child Adj. Age

Number

N

Weeks Premature

Number

Y

Gender

Text

Y

Options are:

Male

Female

Caregiver ID

Number

N

Caregiver First Name

Text

Y

Caregiver Middle Initial

Text

N

Caregiver Last Name

Text

Y

Caregiver Street Address

Text

Y

Relationship to Child

Text

Y

Options are:

Foster parent

Guardian

Grandparent or other relative

Father

Mother

Child care provider

Teacher

Other

City

Text

Y

State/Province

Text

Y

Valid options are states/provinces included in the drop-down menu on the Child Profile.

Zip/Postal code

Text

Y

Country

Text

Y

Valid options are countries included in the drop-down menu on the Child Profile.

Home Telephone Number

Text

Y

Other Telephone Number

Text

N

Email Address

Text

N

Persons assisting in questionnaire completion

Text

N

Age Interval

Number

Y

Options are:

2, 4, 6, 8, 9, 10, 12, 14, 16, 18, 20, 22, 24, 27, 30, 33, 36, 42, 48, 54, 60

Language

Text

Y

Options are:

English

Spanish

Long or Short Form

Text

Y

Options are:

Long

Short

Reason for out of range interval

Text

N

Communication Score

Number

N

Communication Cutoff

Number

N

Gross Motor Score

Number

N

Gross Motor Cutoff

Number

N

Fine Motor Score

Number

N

Fine Motor Cutoff

Number

N

Problem Solving Score

Number

N

Problem Solving Cutoff

Number

N

Personal-Social Score

Number

N

Personal-Social Cutoff

Number

N

Communication Q1

Text

Y

Valid Options are: Yes, Sometimes, Not Yet, Response Missing, or Y, S, N, RM

Communication Q2

Text

Y

Valid options are: Yes, Sometimes, Not Yet, Response Missing, or Y, S, N, RM

Communication Q3

Text

Y

Valid options are: Yes, Sometimes, Not Yet, Response Missing, or Y, S, N, RM

Communication Q4

Text

Y

Valid options are: Yes, Sometimes, Not Yet, Response Missing, or Y, S, N, RM

Communication Q5

Text

Y

Valid options are: Yes, Sometimes, Not Yet, Response Missing, or Y, S, N, RM

Communication Q6

Text

Y

Valid options are: Yes, Sometimes, Not Yet, Response Missing, or Y, S, N, RM

Gross Motor Q1

Text

Y

Valid options are: Yes, Sometimes, Not Yet, Response Missing, or Y, S, N, RM

Gross Motor Q2

Text

Y

Valid options are: Yes, Sometimes, Not Yet, Response Missing, or Y, S, N, RM

Gross Motor Q3

Text

Y

Valid options are: Yes, Sometimes, Not Yet, Response Missing, or Y, S, N, RM

Gross Motor Q4

Text

Y

Valid options are: Yes, Sometimes, Not Yet, Response Missing, or Y, S, N, RM

Gross Motor Q5

Text

Y

Valid options are: Yes, Sometimes, Not Yet, Response Missing, or Y, S, N, RM

Gross Motor Q6

Text

Y

Valid options are: Yes, Sometimes, Not Yet, Response Missing, or Y, S, N, RM

Fine Motor Q1

Text

Y

Valid options are: Yes, Sometimes, Not Yet, Response Missing, or Y, S, N, RM

Fine Motor Q2

Text

Y

Valid options are: Yes, Sometimes, Not Yet, Response Missing, or Y, S, N, RM

Fine Motor Q3

Text

Y

Valid options are: Yes, Sometimes, Not Yet, Response Missing, or Y, S, N, RM

Fine Motor Q4

Text

Y

Valid options are: Yes, Sometimes, Not Yet, Response Missing, or Y, S, N, RM

Fine Motor Q5

Text

Y

Valid options are: Yes, Sometimes, Not Yet, Response Missing, or Y, S, N, RM

Fine Motor Q6

Text

Y

Valid options are: Yes, Sometimes, Not Yet, Response Missing, or Y, S, N, RM

Problem Solving Q1

Text

Y

Valid options are: Yes, Sometimes, Not Yet, Response Missing, or Y, S, N, RM

Problem Solving Q2

Text

Y

Valid options are: Yes, Sometimes, Not Yet, Response Missing, or Y, S, N, RM

Problem Solving Q3

Text

Y

Valid options are: Yes, Sometimes, Not Yet, Response Missing, or Y, S, N, RM

Problem Solving Q4

Text

Y

Valid options are: Yes, Sometimes, Not Yet, Response Missing, or Y, S, N, RM

Problem Solving Q5

Text

Y

Valid options are: Yes, Sometimes, Not Yet, Response Missing, or Y, S, N, RM

Problem Solving Q6

Text

Y

Valid options are: Yes, Sometimes, Not Yet, Response Missing, or Y, S, N, RM

Personal-Social Q1

Text

Y

Valid options are: Yes, Sometimes, Not Yet, Response Missing, or Y, S, N, RM

Personal-Social Q2

Text

Y

Valid options are: Yes, Sometimes, Not Yet, Response Missing, or Y, S, N, RM

Personal-Social Q3

Text

Y

Valid options are: Yes, Sometimes, Not Yet, Response Missing, or Y, S, N, RM

Personal-Social Q4

Text

Y

Valid options are: Yes, Sometimes, Not Yet, Response Missing, or Y, S, N, RM

Personal-Social Q5

Text

Y

Valid options are: Yes, Sometimes, Not Yet, Response Missing, or Y, S, N, RM

Personal-Social Q6

Text

Y

Valid options are: Yes, Sometimes, Not Yet, Response Missing, or Y, S, N, RM

Overall Q1

Text

Y

Valid Options are: Yes, No, Response Missing  or Y, N, RM

Overall Q1 Comments

Text

N

Overall Q2

Text

Y

Valid Options are: Yes, No, Response Missing  or Y, N, RM

Overall Q2 Comments

Text

N

Overall Q3

Text

Y

Valid Options are: Yes, No, Response Missing  or Y, N, RM

Overall Q3 Comments

Text

N

Overall Q4

Text

Y

Valid Options are: Yes, No, Response Missing  or Y, N, RM

Overall Q4 Comments

Text

N

Overall Q5

Text

Y

Valid Options are: Yes, No, Response Missing  or Y, N, RM

Overall Q5 Comments

Text

N

Overall Q6

Text

Y

Valid Options are: Yes, No, Response Missing  or Y, N, RM

Overall Q6 Comments

Text

N

Overall Q7

Text

Y

Valid Options are: Yes, No, Response Missing  or Y, N, RM

Overall Q7 Comments

Text

N

Overall Q8

Text

Y

Valid Options are: Yes, No, Response Missing  or Y, N, RM

Overall Q8 Comments

Text

N

Overall Q9

Text

Y

Valid Options are: Yes, No, Response Missing  or Y, N, RM

Overall Q9 Comments

Text

N

Overall Q10

Text

Y

Valid Options are: Yes, No, Response Missing  or Y, N, RM

Overall Q10 Comments

Text

N

Field Name

Data Type

Required

Special Instructions

Program

Text

N

Child ID

Text

N

Alt. ID

Text

N

Child First Name

Text

Y

Child Middle Initial

Text

N

Child Last Name

Text

Y

Child DOB

Date

Y

Format: mm/dd/yyyy

Gender

Text

Y

Options are:

Male

Female

Date Questionnaire Completed

Date

Y

Format: mm/dd/yyyy

Caregiver ID

Number

N

Caregiver First Name

Text

Y

Caregiver Last Name

Text

Y

Relationship to Child

Text

Y

Options are:

Foster parent

Guardian

Grandparent or other relative

Father

Mother

Child Care Provider

Teacher

Other

Telephone Number

Text

Y

Mailing Address

Text

Y

City

Text

Y

State

Text

Y

Valid options are states/provinces included in the drop-down menu on the Caregiver Profile.

Zip Code

Text

Y

Country

Text

Y

Valid options are countries included in the drop-down menu on the Caregiver Profile.

Persons assisting in questionnaire completion

Text

N

Child Chronological Age

Number

N

Language

Text

Y

Options are:

English

Spanish

Age Interval

Number

Y

Options are:

6, 12, 18, 24, 30, 36, 48, 60

Long or Short Form

Text

Y

Options are:

Long

Short

Child's ASQ:SE-2 Score

Number

N

Cutoff Score

Number

N

Field Name

Data Type

Required

Special Instructions

Q1

Text

Y

Options are: Most of the time, Sometimes, Rarely or Never, Missing, or MT, S, RN, RM

Q1 Concern

Text

N

Options are: Yes, No, or Y, N (Field can also be left blank.)

Q2

Text

Y

Options are: Most of the time, Sometimes, Rarely or Never, Missing, or MT, S, RN, RM

Q2 Concern

Text

N

Options are: Yes, No, or Y, N (Field can also be left blank.)

Q3

Text

Y

Options are: Most of the time, Sometimes, Rarely or Never, Missing, or MT, S, RN, RM

Q3 Concern

Text

N

Options are: Yes, No, or Y, N (Field can also be left blank.)

Q4

Text

Y

Options are: Most of the time, Sometimes, Rarely or Never, Missing, or MT, S, RN, RM

Q4 Concern

Text

N

Options are: Yes, No, or Y, N (Field can also be left blank.)

Q5

Text

Y

Options are: Most of the time, Sometimes, Rarely or Never, Missing, or MT, S, RN, RM

Q5 Concern

Text

N

Options are: Yes, No, or Y, N (Field can also be left blank.)

Q6

Text

Y

Options are: Most of the time, Sometimes, Rarely or Never, Missing, or MT, S, RN, RM

Q6 Concern

Text

N

Options are: Yes, No, or Y, N (Field can also be left blank.)

Q7

Text

Y

Options are: Most of the time, Sometimes, Rarely or Never, Missing, or MT, S, RN, RM

Q7 Concern

Text

N

Options are: Yes, No, or Y, N (Field can also be left blank.)

Q8

Text

Y

Options are: Most of the time, Sometimes, Rarely or Never, Missing, or MT, S, RN, RM

Q8 Concern

Text

N

Options are: Yes, No, or Y, N (Field can also be left blank.)

Q9

Text

Y

Options are: Most of the time, Sometimes, Rarely or Never, Missing, or MT, S, RN, RM

Q9 Concern

Text

N

Options are: Yes, No, or Y, N (Field can also be left blank.)

Q10

Text

Y

Options are: Most of the time, Sometimes, Rarely or Never, Missing, or MT, S, RN, RM

Q10 Concern

Text

N

Options are: Yes, No, or Y, N (Field can also be left blank.)

Q11

Text

Y

Options are: Most of the time, Sometimes, Rarely or Never, Missing, or MT, S, RN, RM

Q11 Concern

Text

N

Options are: Yes, No, or Y, N (Field can also be left blank.)

Q12

Text

Y

Options are: Most of the time, Sometimes, Rarely or Never, Missing, or MT, S, RN, RM

Q12 Concern

Text

N

Options are: Yes, No, or Y, N (Field can also be left blank.)

Q13

Text

Y

Options are: Most of the time, Sometimes, Rarely or Never, Missing, or MT, S, RN, RM

Q13 Concern

Text

N

Options are: Yes, No, or Y, N (Field can also be left blank.)

Q13 Comment

Text

N

Q14

Text

Y

Options are: Most of the time, Sometimes, Rarely or Never, Missing, or MT, S, RN, RM

Q14 Concern

Text

N

Options are: Yes, No, or Y, N (Field can also be left blank.)

Q15

Text

Y

Options are: Most of the time, Sometimes, Rarely or Never, Missing, or MT, S, RN, RM

Q15 Concern

Text

N

Options are: Yes, No, or Y, N (Field can also be left blank.)

Q16

Text

Y

Options are: Most of the time, Sometimes, Rarely or Never, Missing, or MT, S, RN, RM

Q16 Concern

Text

N

Options are: Yes, No, or Y, N (Field can also be left blank.)

Q16 Comment

Text

N

Q17 Concern

Text

Y

Options are: Yes, No, or Y, N (Field can also be left blank.)

Q17 Comment

Text

N

Q18 Concern

Text

Y

Q18 Comment

Text

N

Options are: Yes, No, or Y, N (Field can also be left blank.)

Q19 Comment

Text

N