ASQ-3 Special Release Extension Request Form

Please fill out the following form to request an extension on the ASQ-3 Special Release materials.

First Name*
Last Name*
Your Title/Position*
Email*
Phone*
I am an authorized user of ASQ-3 questionnaires and am signing the agreement on behalf of:
Organization Name*
Organization Address*
Street Address Address Line 2 City State / Province / Region ZIP / Postal Code Country
Organization Website/URL*
My organization has previously purchased ASQ-3 Questionnaires and/or ASQ-3 in Spanish Questionnaires. I understand that I may be contacted to confirm this and provide a valid proof of purchase.
Confirmation*
I confirm that
- I represent an organization engaged in direct service provision to children and families.
- The organization’s employees work one-on-one with families to implement screening during interactive home visits, parent conferences, and telehealth appointments.
- The organization’s employees now need to provide these services virtually or remotely rather than in person.
- The organization is responsible for providing employees with guidance on use of the Special Release materials, virtual service delivery, and any relevant privacy considerations.
ASQ^®-3 Special Release Permission Agreement

The following paragraphs constitute the Permission Agreement (“Agreement”) for the ASQ Special Release. “Materials” refers to alternate format download files for Ages & Stages Questionnaires^®, Third Edition: A Parent-Completed Child Monitoring System (ASQ^®-3) and/or Ages & Stages Questionnaires^® in Spanish, Third Edition: A Parent-Completed Child Monitoring System (ASQ^®-3 Spanish). By accessing or using the Materials, I (“the User”) am accepting the terms and conditions of this Agreement with Paul H. Brookes Publishing Co., Inc. (“Brookes Publishing Co.”).

Brookes Publishing Co. authorizes the User to: a) share the Materials with their organization’s employees by email or text to support interactive virtual service provision to children and families; and b) post the Materials for access on a local area network (LAN) or intranet, provided that all employees with access work at the same office as the User. The Materials may not be posted on the Internet under any circumstances.

Brookes Publishing authorizes the User and employees of the User’s organization to: a) share the Materials in JPEG format (ASQ-3 English and/or ASQ-3 Spanish questionnaire images) directly with individual families by text or email for viewing during interactive web conferences and telephone calls as they implement ASQ-3 screening; and b) use the Materials in fillable PDF (ASQ-3 English and/or ASQ-3 Spanish Information Summary sheets) to record screening responses, results, and follow-up actions during interactive web conferences and telephone calls.

Brookes Publishing Co. authorizes the User and employees of the User’s organization to access and use the Materials through June 30, 2024.

With the exception of this temporary permission to email and text the Materials, the User and employees of the User’s organization must abide by the ASQ-3 End User License Agreement and Photocopying Release and ASQ-3 Spanish End User License Agreement and Photocopying Release.
Electronic Signature*

By entering your name, you are signing the form electronically and agree it is the legal equivalent of your manual signature on this agreement. By submitting this form you agree to receive email communications from ASQ and Brookes Publishing.

ASQ-3 Special Release Extension Request Form

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