Screening Forms

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 


       Type directly onto the documents, download, save and attach in an email to

                                                         [email protected]

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