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.  Ethnic & Racial Demographic form  

   
 8.  MN Language Survey
     
     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

                                                       [email protected]



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