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Newborn Screening Ontario

Developmental Surveillance Report Form

1 Start 2 Complete
Patient Information
Physician Information
(First Name, Last Name)
(i.e. pediatrician, ID)
ASQ3 Administration
(e.g. 2 months, 4 months, etc)
Please enter the total score for each developmental area and indicate whether it is above the cut-off (i.e. white area - normal), close to the cut-off (i.e. grey area – provide learning activities/monitor), or below the cut-off (i.e. black area – further assessment needed).
A) Communication
B) Gross Motor
C) Fine Motor
D) Problem Solving
Next Assessment:
Will you continue to follow this child for developmental assessments?