Developmental Surveillance Report Form

It is recommended that CMV screen positive infants be followed for developmental surveillance by a dedicated community pediatrician throughout childhood. The ASQ3 screening tool should be used and the recommended surveillance schedule is as follows:

• 3 assessments in the first year
• 3 assessments in the seconf year (including one at 14 and 22 months)
• 1 assessment in the 3rd, 4th, and 5th years

Please use the link below to securely submit your ASQ3 scores following each assessment. If your preference is to submit a consult note with the scores, kindly fax them to 833-377-0518.

Developmental Surveillance Report Form