8.5 Quick Reference Guide
8.5.1 Import Quick Reference Guide
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I would like to Import… |
Import Data Template |
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Child and Caregiver Profile Data Template |
Caregiver Profile Data Only Template |
ASQ-3 Data Template |
ASQ:SE Data Templates |
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Child Profile Data Only |
X |
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Child Profile and one Caregiver Profile |
X |
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Caregiver Profile Only |
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X |
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ASQ-3 Screening Data for Existing Child Profiles |
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X |
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Child Profile, Caregiver Profile, and ASQ-3 Screening Data |
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X |
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ASQ:SE Screening Data for existing Child Profiles |
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X |
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Child Profile, Caregiver Profile, and ASQ:SE Screening Data |
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X |
8.5.2 Updating Data Quick Reference Guide
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I would like to Update… |
Use this Data Template |
Include this Identifier in Data Template |
Results |
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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. |
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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. |
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Existing Caregiver Profile Only |
Caregiver Profile Only |
Caregiver ID |
Only the Caregiver Profile will be updated. |
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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. |
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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. |
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New ASQ:SE Screening for Existing Child and Caregiver Profile |
ASQ:SE Templates |
Child ID or Alt. ID Caregiver ID |
The newly imported ASQ:SE Screening will be added to the existing Child Profile. |
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New ASQ:SE Screening for Existing Child and New Caregiver Profile |
ASQ:SE Templates |
Child ID or Alt. ID |
The newly imported ASQ:SE Screening will be added to the existing Child Profile, and a new Caregiver Profile will be created. |
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Link New Caregiver Profile to Existing Child Profile |
Caregiver Profile |
Alt. ID |
A new Caregiver Profile will be linked to an existing Child Profile. |
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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. |
8.5.3 Data Requirements for Child and Caregiver Data Template
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Field Name |
Data Type |
Required |
Special Instructions |
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Program |
Text |
N |
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Child ID |
Text |
N |
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Alt. ID |
Text |
N |
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Last Name |
Text |
Y |
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Middle Name |
Text |
N |
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First Name |
Text |
Y |
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Status |
Text |
Y |
Options are: Active Archived |
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DOB |
Date |
Y |
Format: mm/dd/yyyy |
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Weeks Premature |
Number |
Y |
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Adjusted Age |
Text |
N |
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Gender |
Text |
Y |
Options are: Male |
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Birth Weight |
Text |
N |
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Ethnicity |
Text |
N |
Options are: Caucasian African American Hispanic or Latino Asian Middle-Eastern Native American Hawaiian, Pacific Islander Unknown
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Address1 |
Text |
Y |
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Address2 |
Text |
N |
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Address3 |
Text |
N |
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City |
Text |
Y |
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County/District |
Text |
N |
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State/Province |
Text |
Y |
Valid options are full names of states/provinces included in the drop-down menu on the Child Profile.
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Zip/Postal code |
Text |
Y |
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Country |
Text |
Y |
Valid options are countries included in the drop-down menu on the Child Profile.
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Phone |
Text |
Y |
Format: 999-999-9999 |
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Primary home language |
Text |
N |
Options are: English Spanish French Korean Chinese Other |
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Language(s) spoken in the home |
Text |
N |
Options are: Spanish French Korean Chinese Other N/A |
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Primary Care Physician |
Text |
N |
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Clinic/Practice Name |
Text |
N |
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Clinic Address1 |
Text |
N |
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Clinic Address2 |
Text |
N |
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Clinic Address3 |
Text |
N |
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Clinic City |
Text |
N |
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Clinic State/Province |
Text |
N |
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Clinic Zip/Postal Code |
Text |
N |
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Clinic Phone |
Text |
N |
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Clinic Fax |
Text |
N |
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Clinic Email |
Text |
N |
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Medical risk factors |
Text |
N |
Options are: Yes or Y, No or N |
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Environmental risk factors |
Text |
N |
Options are: Yes or Y, No or N |
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Medical conditions |
Text |
N |
Options are: Yes or Y, No or N |
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Other agencies involved |
Text |
N |
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Caregiver ID |
Text |
N |
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Caregiver Prefix* |
Text |
N |
Options are: Mr. Mrs. Ms. Miss Dr. |
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Caregiver First Name* |
Text |
N |
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Caregiver Middle Name |
Text |
N |
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Caregiver Last Name* |
Text |
N |
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Relationship to child* |
Text |
N |
Options are: Foster parent Guardian Grandparent or other relative Father Mother Child care provider Teacher Other |
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Caregiver Phone* |
Text |
N |
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Caregiver Alternate Phone |
Text |
N |
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Caregiver Email |
Text |
N |
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Caregiver Primary Home Language* |
Text |
N |
Options are: English Spanish French Korean Chinese Other |
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Secondary Home Language* |
Text |
N |
Options are: English Spanish French Korean Chinese Other N/A |
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Primary Caregiver* |
Text |
N |
Options are: Yes No |
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Caregiver Address1* |
Text |
N |
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Caregiver Address2 |
Text |
N |
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Caregiver Address3 |
Text |
N |
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Caregiver City* |
Text |
N |
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Caregiver County/District |
Text |
N |
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Caregiver State/Province* |
Text |
N |
Valid Options are states/provinces included in the drop-down menu on the Caregiver Profile.
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Caregiver Zip/Postal Code* |
Text |
N |
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Caregiver Country* |
Text |
N |
Valid Options are states/provinces included in the drop-down menu on the Caregiver Profile.
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*Note: Caregiver Profiles are not required for the Child and Caregiver Template. If you opt to include Caregiver Profile information, fields marked with an asterisk (*) will be required fields.
8.5.4 Data Requirements for Caregiver Data Template
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Field Name |
Data Type |
Required |
Special Instructions |
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Program |
Text |
N |
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Caregiver ID |
Text |
N |
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Caregiver Prefix |
Text |
Y |
Options are: Mr. Mrs. Ms. Miss Dr. |
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Caregiver First Name |
Text |
Y |
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Caregiver Middle Name |
Text |
N |
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Caregiver Last Name |
Text |
Y |
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Text |
N |
To link the Caregiver Profile to an existing Child Profile, enter the Alternate Child ID in this field. |
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Relationship to Child |
Text |
Y |
Options are: Foster parent Guardian Grandparent or other relative Father Mother Child care provider Teacher Other |
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Caregiver Phone |
Text |
Y |
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Caregiver Alternate Phone |
Text |
N |
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Caregiver Email |
Text |
N |
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Caregiver Primary Home Language |
Text |
Y |
Options are: English Spanish French Korean Chinese Other |
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Secondary Home Language |
Text |
Y |
Options are: English Spanish French Korean Chinese Other N/A |
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Primary Caregiver |
Text |
Y |
Options are: Yes No |
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Caregiver Address1 |
Text |
Y |
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Caregiver Address2 |
Text |
N |
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Caregiver Address3 |
Text |
N |
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Caregiver City* |
Text |
N |
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Caregiver County/District |
Text |
N |
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Caregiver State/Province |
Text |
Y |
Valid Options are states/provinces included in the drop-down menu on the Caregiver Profile.
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Caregiver Zip/Postal Code |
Text |
Y |
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Caregiver Country |
Text |
Y |
Valid Options are states/provinces included in the drop-down menu on the Caregiver Profile.
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8.5.5 Data Requirements for ASQ-3 Data Template
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Field Name |
Data Type |
Required |
Special Instructions |
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Program |
Text |
N |
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Child ID |
Text |
N |
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Alt. ID |
Text |
N |
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Date ASQ Completed |
Date |
Y |
Format: mm/dd/yyyy |
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Child First Name |
Text |
Y |
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Child Middle Initial |
Text |
N |
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Child Last Name |
Text |
T |
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Child DOB |
Date |
Y |
Format: mm/dd/yyyy |
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Child Adj. Age |
Number |
N |
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Weeks Premature |
Number |
Y |
|
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Gender |
Text |
Y |
Options are: Male Female |
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Caregiver ID |
Number |
N |
|
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Caregiver First Name |
Text |
Y |
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Caregiver Middle Initial |
Text |
N |
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Caregiver Last Name |
Text |
Y |
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Caregiver Street Address |
Text |
Y |
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Relationship to Child |
Text |
Y |
Options are: Foster parent Guardian Grandparent or other relative Father Mother Child care provider Teacher Other |
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City |
Text |
Y |
|
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State/Province |
Text |
Y |
Valid options are states/provinces included in the drop-down menu on the Child Profile.
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Zip/Postal code |
Text |
Y |
|
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Country |
Text |
Y |
Valid options are countries included in the drop-down menu on the Child Profile.
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Home Telephone Number |
Text |
Y |
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Other Telephone Number |
Text |
N |
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Email Address |
Text |
N |
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Persons assisting in questionnaire completion |
Text |
N |
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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 |
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Long or Short Form |
Text |
Y |
Options are: Long Short |
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Reason for out of range interval |
Text |
N |
|
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Communication Score |
Number |
N |
|
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Communication Cutoff |
Number |
N |
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Gross Motor Score |
Number |
N |
|
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Gross Motor Cutoff |
Number |
N |
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Fine Motor Score |
Number |
N |
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Fine Motor Cutoff |
Number |
N |
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Problem Solving Score |
Number |
N |
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Problem Solving Cutoff |
Number |
N |
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Personal-Social Score |
Number |
N |
|
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Personal-Social Cutoff |
Number |
N |
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Communication Q1 |
Text |
Y |
Valid Options are: Yes, Sometimes, Not Yet, Response Missing, or Y, S, N, RM |
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Communication Q2 |
Text |
Y |
Valid options are: Yes, Sometimes, Not Yet, Response Missing, or Y, S, N, RM |
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Communication Q3 |
Text |
Y |
Valid options are: Yes, Sometimes, Not Yet, Response Missing, or Y, S, N, RM |
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Communication Q4 |
Text |
Y |
Valid options are: Yes, Sometimes, Not Yet, Response Missing, or Y, S, N, RM |
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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 |
|
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Overall Q2 |
Text |
Y |
Valid Options are: Yes, No, Response Missing or Y, N, RM |
|
Overall Q2 Comments |
Text |
N |
|
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Overall Q3 |
Text |
Y |
Valid Options are: Yes, No, Response Missing or Y, N, RM |
|
Overall Q3 Comments |
Text |
N |
|
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Overall Q4 |
Text |
Y |
Valid Options are: Yes, No, Response Missing or Y, N, RM |
|
Overall Q4 Comments |
Text |
N |
|
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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 |
|
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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 |
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8.5.6 Data Requirements for ASQ:SE-2 Data Templates
(2, 6, 12, 18, 24, 30, 36, 48, and 60 month intervals)
The following fields are included in all ASQ:SE-2 Data Templates:
|
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 Score |
Number |
N |
|
|
Cutoff Score |
Number |
N |
|
ASQ:SE-2 6 Month Template
|
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.) |
|
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.) |
|
Q14 Comment |
Text |
N |
|
|
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.) |
|
Q17 |
Text |
Y |
Options are: Most of the time, Sometimes, Rarely or Never, Missing, or MT, S, RN, RM |
|
Q17 Concern |
Text |
N |
Options are: Yes, No, or Y, N (Field can also be left blank.) |
|
Q18 |
Text |
Y |
Options are: Most of the time, Sometimes, Rarely or Never, Missing, or MT, S, RN, RM |
|
Q18 Concern |
Text |
N |
Options are: Yes, No, or Y, N (Field can also be left blank.) |
|
Q19 |
Text |
Y |
Options are: Most of the time, Sometimes, Rarely or Never, Missing, or MT, S, RN, RM |
|
Q19 Concern |
Text |
N |
Options are: Yes, No, or Y, N (Field can also be left blank.) |
|
Q19 Comment |
Text |
N |
|
|
Q20 |
Text |
N |
|
|
Q21 |
Text |
N |
|
|
Q22 |
Text |
N |
|
ASQ:SE-2 12 Month Template
|
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.) |
|
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.) |
|
Q14 Comment |
Text |
N |
|
|
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.) |
|
Q17 |
Text |
Y |
Options are: Most of the time, Sometimes, Rarely or Never, Missing, or MT, S, RN, RM |
|
Q17 Concern |
Text |
N |
Options are: Yes, No, or Y, N (Field can also be left blank.) |
|
Q18 |
Text |
Y |
Options are: Most of the time, Sometimes, Rarely or Never, Missing, or MT, S, RN, RM |
|
Q18 Concern |
Text |
N |
Options are: Yes, No, or Y, N (Field can also be left blank.) |
|
Q19 |
Text |
Y |
Options are: Most of the time, Sometimes, Rarely or Never, Missing, or MT, S, RN, RM |
|
Q19 Concern |
Text |
N |
Options are: Yes, No, or Y, N (Field can also be left blank.) |
|
Q19 Comment |
Text |
N |
|
|
Q20 |
Text |
N |
|
|
Q21 |
Text |
N |
|
|
Q22 |
Text |
N |
|
|
Q22 Comment |
Text |
N |
|
|
Q23 |
Text |
N |
|
|
Q24 |
Text |
N |
|
|
Q25 |
Text |
N |
|
ASQ:SE-2 18 Month Template
|
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.) |
|
Q11 Comment |
Text |
N |
|
|
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.) |
|
Q12 Comment |
Text |
N |
|
|
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.) |
|
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.) |
|
Q17 |
Text |
Y |
Options are: Most of the time, Sometimes, Rarely or Never, Missing, or MT, S, RN, RM |
|
Q17 Concern |
Text |
N |
Options are: Yes, No, or Y, N (Field can also be left blank.) |
|
Q18 |
Text |
Y |
Options are: Most of the time, Sometimes, Rarely or Never, Missing, or MT, S, RN, RM |
|
Q18 Concern |
Text |
N |
Options are: Yes, No, or Y, N (Field can also be left blank.) |
|
Q19 |
Text |
Y |
Options are: Most of the time, Sometimes, Rarely or Never, Missing, or MT, S, RN, RM |
|
Q19 Concern |
Text |
N |
Options are: Yes, No, or Y, N (Field can also be left blank.) |
|
Q20 |
Text |
Y |
|
|
Q20 Concern |
Text |
N |
|
|
Q21 |
Text |
Y |
|
|
Q21 Concern |
Text |
N |
|
|
Q22 |
Text |
Y |
|
|
Q22 Concern |
Text |
N |
|
|
Q23 |
Text |
Y |
|
|
Q23 Concern |
Text |
N |
|
|
Q24 |
Text |
Y |
|
|
Q24 Concern |
Text |
N |
|
|
Q25 |
Text |
Y |
|
|
Q25 Concern |
Text |
N |
|
|
Q26 |
Text |
Y |
|
|
Q26 Concern |
Text |
N |
|
|
Q26 Comment |
|
|
|
|
Q27 |
|
|
|
|
Q28 |
|
|
|
|
Q29 |
|
|
|
ASQ:SE-2 24 Month Template
|
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.) |
|
Q11 Comment |
Text |
N |
|
|
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.) |
|
Q17 |
Text |
Y |
Options are: Most of the time, Sometimes, Rarely or Never, Missing, or MT, S, RN, RM |
|
Q17 Concern |
Text |
N |
Options are: Yes, No, or Y, N (Field can also be left blank.) |
|
Q18 |
Text |
Y |
Options are: Most of the time, Sometimes, Rarely or Never, Missing, or MT, S, RN, RM |
|
Q18 Concern |
Text |
N |
Options are: Yes, No, or Y, N (Field can also be left blank.) |
|
Q19 |
Text |
Y |
Options are: Most of the time, Sometimes, Rarely or Never, Missing, or MT, S, RN, RM |
|
Q19 Concern |
Text |
N |
Options are: Yes, No, or Y, N (Field can also be left blank.) |
|
Q20 |
Text |
Y |
Options are: Most of the time, Sometimes, Rarely or Never, Missing, or MT, S, RN, RM |
|
Q20 Concern |
Text |
N |
Options are: Yes, No, or Y, N (Field can also be left blank.) |
|
Q21 |
Text |
Y |
Options are: Most of the time, Sometimes, Rarely or Never, Missing, or MT, S, RN, RM |
|
Q21 Concern |
Text |
N |
Options are: Yes, No, or Y, N (Field can also be left blank.) |
|
Q21 Comment |
Text |
N |
|
|
Q22 |
Text |
Y |
Options are: Most of the time, Sometimes, Rarely or Never, Missing, or MT, S, RN, RM |
|
Q22 Concern |
Text |
N |
Options are: Yes, No, or Y, N (Field can also be left blank.) |
|
Q23 |
Text |
Y |
Options are: Most of the time, Sometimes, Rarely or Never, Missing, or MT, S, RN, RM |
|
Q23 Concern |
Text |
N |
Options are: Yes, No, or Y, N (Field can also be left blank.) |
|
Q24 |
Text |
Y |
Options are: Most of the time, Sometimes, Rarely or Never, Missing, or MT, S, RN, RM |
|
Q24 Concern |
Text |
N |
Options are: Yes, No, or Y, N (Field can also be left blank.) |
|
Q25 |
Text |
Y |
Options are: Most of the time, Sometimes, Rarely or Never, Missing, or MT, S, RN, RM |
|
Q25 Concern |
Text |
N |
Options are: Yes, No, or Y, N (Field can also be left blank.) |
|
Q26 |
Text |
Y |
Options are: Most of the time, Sometimes, Rarely or Never, Missing, or MT, S, RN, RM |
|
Q26 Concern |
Text |
N |
Options are: Yes, No, or Y, N (Field can also be left blank.) |
|
Q26 Comment |
Text |
N |
|
|
Q27 |
Text |
N |
|
|
Q28 |
Text |
N |
|
|
Q29 |
Text |
N |
|
ASQ:SE-2 30 Month Template
ASQ:SE-2 36 Month Template
ASQ:SE-2 48 Month Template
ASQ:SE-2 60 Month Template
See also