Transcription of CUTOFF POINTS FOR ASQ:SE-2 SCORING - famsys.org
1 ASQ:SE-2 Score Sheet 6/04/18 Healthy Families-TIP New JerseyASQ Social-Emotional 2 Score Sheet Use this sheet to submit scores from the ASQ:SE-2 for data entry. Use the chart on the bottom of the page to determine under cut-off score. Caretaker 1 s Identifier2. Home Visitor s Name PC1 Initials (2 let) Year of Birth (2 num) Program CodeUnique 6 Digit Identifier FirstLast 3. Target Child s Birth Date4. Date CompletedMonthDayYear MonthDayYear 5. Target Child s Developmental Age (Check only one)6. Target Child s Name 2 months 30 months First Last 6 months 36 months 12 months 48 months 18 months 60 months 24 months Score Above CUTOFF 7.
2 TOTAL SCORE Yes No If Q7 is an above CUTOFF score, answer questions below 8. Was target child referred?9. Reason target child was not referred fordevelopmental services: PC1 Refused TC already receiving developmental services TC not eligible for services Rescreening needed. PE will rescreen within 30 days Referral not needed. TC did not score above Has target child startedreceiving developmentalservices? Yes No Yes (answer Q10 and fill out service referral form) No (answer Q9, skip Q10) Date Form Submitted Reviewer s Initials Date of Data Entry Initials of Data Entry Operator CUTOFF POINTS FOR ASQ:SE-2 SCORING ASQ:SE-2 age interval CUTOFF score 2 month 35 6 month 45 12 month 50 18 month 65 24 month 65 30 month 85 36 month 105 48 month 85 60 month 95
