Along with the forms below, please bring a copy of your child's birth certificate and immunization records to their screening appointment.
Forms to be completed for Screenings:
1. Screening Consent form
2. Release of Information form
3. Health History form
4. Hearing and Vision Worksheet
5. Screening Enrollment Form
6. ISD #181 Enrollment Form
7. MN Language Survey
8. Ethnic & Racial Demographic Designation Form
9. ASQ:SE-2 Parent Information for completing the ASQ:SE-2
Please choose the ASQ form below appropriate for your child's age on their screening day:
ASQ:SE-2 for 2 yrs, 9 mo-3 yrs, 5 mo
ASQ:SE-2 for 3 yrs, 6 mo-4 yrs, 5 mo
ASQ:SE-2 for 4 yrs, 6 mos- 5 yrs, 5 mo
You can either:
print the forms to complete them by hand and bring them to your appointment
Or
Type directly onto the documents, download, save and attach in an email to