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Fill Out Your Asq 14 Month Questionnaire Form

The ASQ 14 Month Questionnaire is a vital tool designed to assess the developmental milestones of infants aged 13 months to 14 months and 30 days. By answering questions related to communication, gross motor skills, fine motor skills, problem solving, and personal-social development, parents and caregivers can gain valuable insights into a child's growth. Completing this questionnaire fosters a better understanding of the child's abilities and supports timely interventions if necessary.

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Article Structure

The Ages & Stages Questionnaires® 14 Month Questionnaire is a vital tool designed for parents, guardians, and childcare providers to assess the developmental milestones of infants aged 13 months to 14 months and 30 days. Its primary objective is to identify the progress of babies in various areas such as communication, gross motor skills, fine motor skills, problem-solving abilities, and personal-social interactions. This questionnaire guides the respondent through a series of questions that require assessing the child’s activities and responses, ranging from verbal communication, like saying a few words, to physical tasks such as standing or walking. Each section emphasizes a simple reporting format, encouraging users to mark whether the child performs the activity regularly, sometimes, or not yet. To ensure the most accurate results, the form recommends conducting activities in a playful manner and under optimal conditions, such as when the child is well-rested and content. The information gathered through this questionnaire not only aids in monitoring developmental progress but also fosters communication between caregivers and healthcare professionals, allowing timely support if any concerns arise. Completing this form also reflects a caregiver's involvement in nurturing the child’s growth during this critical stage of development.

Asq 14 Month Questionnaire Example

Ages & Stages

Questionnaires®

14 13 months 0 days through 14 months 30 days

Month Questionnaire

Please provide the following information. Use black or blue ink only and print legibly when completing this form.

Date ASQ completed:

Baby’s information

	Middle
Baby’s first name:	initial:	Baby’s last name:
		If baby was born 3	Baby’s gender:
		or more weeks	Male	Female
		prematurely, # of	Male	Female
		prematurely, # of
Baby’s date of birth:		weeks premature:

Person filling out questionnaire

	Middle	Last name:
First name:	initial:	Last name:
		Relationship to baby:
		Parent	Guardian	Teacher	Child care
		Parent	Guardian	Teacher	provider
					provider
Street address:		Grandparent	Foster	Other:
		or other	parent	Other:
		or other	parent
		relative

	State/	ZIP/
City:	Province:	Postal code:

	Home	Other
	telephone	telephone
Country:	number:	number:

E-mail address:

Names of people assisting in questionnaire completion:

Program Information

	Baby ID #:	Age at administration in months and days:

	Program ID #:	If premature, adjusted age in months and days:

	Program name:


P101140100		Ages & Stages Questionnaires®, Third Edition (ASQ-3™), Squires & Bricker
P101140100		© 2009 Paul H. Brookes Publishing Co. All rights reserved.

14 Month Questionnaire

13 months 0 days through 14 months 30 days

On the following pages are questions about activities babies may do. Your baby may have already done some of the activities described here, and there may be some your baby has not begun doing yet. For each item, please fill in the circle that indi- cates whether your baby is doing the activity regularly, sometimes, or not yet.

Important Points to Remember:

✓

❑ Try each activity with your baby before marking a response.

✓

❑ Make completing this questionnaire a game that is fun for you and your baby.

✓

❑ Make sure your baby is rested and fed.

✓

❑ Please return this questionnaire by _______________.

Notes:

____________________________________________

At this age, many toddlers may not be cooperative when asked to do things. You may need to try the following activities with your baby more than one time. If possible, try the activities when your baby is cooperative. If your baby can do the activity but refuses, mark “yes” for the item.

COMMUNICATION

YES

SOMETIMES

NOT YET

1. Does your baby say three words, such as “Mama,” “Dada,” and “Baba”? (A “word” is a sound or sounds your baby says consistently to mean someone or something.)

2. When your baby wants something, does she tell you by pointing to it?

3. Does your baby shake his head when he means “no” or “yes”?

4. Does your baby point to, pat, or try to pick up pictures in a book?

5. Does your baby say four or more words in addition to “Mama” and “Dada”?

6. When you ask her to, does your baby go into another room to find a fa- miliar toy or object? (You might ask, “Where is your ball?” or say, “Bring me your coat,” or “Go get your blanket.”)

COMMUNICATION TOTAL

GROSS MOTOR

YES

SOMETIMES

NOT YET

1. If you hold both hands just to balance your baby, does he take several steps without tripping or falling? (If your baby already walks alone, mark “yes” for this item.)

2. When you hold one hand just to balance her, does your baby take several steps forward? (If your baby already walks alone, mark “yes” for this item.)

page 2 of 6

E101140200	Ages & Stages Questionnaires®, Third Edition (ASQ-3™), Squires & Bricker
	© 2009 Paul H. Brookes Publishing Co. All rights reserved.

14 Month Questionnaire page 3 of 6

GROSS MOTOR (continued)

YES

SOMETIMESNOT YET

3. Does your baby stand up in the middle of the floor by himself and take several steps forward?

4. Does your baby climb onto furniture or other large objects, such as large climbing blocks?

5. Does your baby bend over or squat to pick up an object from the floor and then stand up again without any support?

6. Does your baby move around by walking, rather than by crawling on his hands and knees?

GROSS MOTOR TOTAL

FINE MOTOR

YES

SOMETIMES

NOT YET

1. Without resting her arm or hand on the table, does your baby pick up a crumb or Cheerio with the tips of her thumb and a finger?

2. Does your baby throw a small ball with a forward arm mo- tion? (If he simply drops the ball, mark “not yet” for this item.)

3. Does your baby help turn the pages of a book? (You may lift a page for her to grasp.)

4. Does your baby stack a small block or toy on top of another one?

(You could also use spools of thread, small boxes, or toys that are about 1 inch in size.)

5. Does your baby make a mark on the paper with the tip

of a crayon (or pencil or pen) when trying to draw?

6. Does your baby stack three small blocks or toys on top of each other by herself?

FINE MOTOR TOTAL

E101140300	Ages & Stages Questionnaires®, Third Edition (ASQ-3™), Squires & Bricker
	© 2009 Paul H. Brookes Publishing Co. All rights reserved.

14 Month Questionnaire page 4 of 6

PROBLEM SOLVING

YES

SOMETIMES

NOT YET

1.If you put a small toy into a bowl or box, does your baby copy you by putting in a toy, although he may not let go of it? (If he already lets go of the toy into a bowl or box, mark “yes” for this item.)

2.Does your baby drop two small toys, one after the other, into a container like a bowl or box? (You may show

her how to do it.)

3.After you scribble back and forth on paper with a crayon (or a pencil or pen), does your baby copy you by scribbling? (If he already scribbles on his own, mark “yes” for this item.)

4.Can your baby drop a crumb or Cheerio into a small, clear bottle (such as a plastic soda-pop bottle or baby bottle)?

5.Does your baby drop several small toys, one after another, into a con- tainer like a bowl or box? (You may show her how to do it.)

6.After you have shown your baby how, does he try to get a small toy that is slightly out of reach by using a spoon, stick, or similar tool?

PROBLEM SOLVING TOTAL

*If Problem Solving Item 2 is marked “yes” or “sometimes,” mark Problem Solving Item 1 as “yes.”

PERSONAL-SOCIAL

YES

SOMETIMES

NOT YET

1. When you dress your baby, does she lift her foot for her shoe, sock, or pant leg?

2. Does your baby roll or throw a ball back to you so that you can return it to him?

3. Does your baby play with a doll or stuffed animal by hugging it?

4. Does your baby feed herself with a spoon, even though she may spill some food?

5. Does your baby help undress himself by taking off clothes like socks, hat, shoes, or mittens?

6. Does your baby get your attention or try to show you something by pulling on your hand or clothes?

PERSONAL-SOCIAL TOTAL

E101140400	Ages & Stages Questionnaires®, Third Edition (ASQ-3™), Squires & Bricker
	© 2009 Paul H. Brookes Publishing Co. All rights reserved.

14 Month Questionnaire page 5 of 6

OVERALL

Parents and providers may use the space below for additional comments.

1. Does your baby use both hands and both legs equally well? If no, explain:

YES

2. Does your baby play with sounds or seem to make words? If no, explain:

YES

3. When your baby is standing, are her feet flat on the surface most of the time?	YES	NO
If no, explain:

4. Do you have concerns that your baby is too quiet or does not make sounds like	YES	NO
other babies do? If yes, explain:

5. Does either parent have a family history of childhood deafness or hearing	YES	NO
impairment? If yes, explain:

E101140500	Ages & Stages Questionnaires®, Third Edition (ASQ-3™), Squires & Bricker
	© 2009 Paul H. Brookes Publishing Co. All rights reserved.

14 Month Questionnaire page 6 of 6

OVERALL (continued)
6. Do you have concerns about your baby’s vision? If yes, explain:	YES	NO

7. Has your baby had any medical problems in the last several months? If yes, explain:

YES

8. Do you have any concerns about your baby’s behavior? If yes, explain:

YES

9. Does anything about your baby worry you? If yes, explain:

YES

E101140600	Ages & Stages Questionnaires®, Third Edition (ASQ-3™), Squires & Bricker
	© 2009 Paul H. Brookes Publishing Co. All rights reserved.

14 Month ASQ-3 Information Summary	13 months 0 days through
	14 months 30 days

Baby’s name: ______________________________________________________

Baby’s ID #: ______________________________________________________

Administering program/provider:

Date ASQ completed: __________________________________________

Date of birth: ______________________________________________

Was age adjusted for prematurity
when selecting questionnaire?	Yes	No

1.SCORE AND TRANSFER TOTALS TO CHART BELOW: See ASQ-3 User’s Guide for details, including how to adjust scores if item responses are missing. Score each item (YES = 10, SOMETIMES = 5, NOT YET = 0). Add item scores, and record each area total. In the chart below, transfer the total scores, and fill in the circles corresponding with the total scores.

	Total	0	5	10	15	20	25	30	35	40	45	50	55	60
Area	Cutoff Score	0	5	10	15	20	25	30	35	40	45	50	55	60
Communication	17.40
Gross Motor	25.80
Fine Motor	23.06
Problem Solving	22.56
Personal-Social	23.18

2.TRANSFER OVERALL RESPONSES: Bolded uppercase responses require follow-up. See ASQ-3 User’s Guide, Chapter 6.

1.	Uses both hands and both legs equally well?	Yes	NO	6.	Concerns about vision?	YES	No
	Comments:				Comments:
2.	Plays with sounds or seems to make words?	Yes	NO	7.	Any medical problems?	YES	No
	Comments:				Comments:
3.	Feet are flat on the surface most of the time?	Yes	NO	8.	Concerns about behavior?	YES	No
	Comments:				Comments:
4.	Concerns about not making sounds?	YES	No	9.	Other concerns?	YES	No
	Comments:				Comments:
5.	Family history of hearing impairment?	YES	No
	Comments:

3.ASQ SCORE INTERPRETATION AND RECOMMENDATION FOR FOLLOW-UP: You must consider total area scores, overall responses, and other considerations, such as opportunities to practice skills, to determine appropriate follow-up.

If the baby’s total score is in the If the baby’s total score is in the If the baby’s total score is in the

area, it is above the cutoff, and the baby’s development appears to be on schedule.

area, it is close to the cutoff. Provide learning activities and monitor.

area, it is below the cutoff. Further assessment with a professional may be needed.

4. FOLLOW-UP ACTION TAKEN: Check all that apply.

______	Provide activities and rescreen in _____ months.
______	Share results with primary health care provider.
______	Refer for (circle all that apply) hearing, vision, and/or behavioral screening.
______	Refer to primary health care provider or other community agency (specify
	reason): __________________________________________________________.
______	Refer to early intervention/early childhood special education.
______	No further action taken at this time
______	Other (specify): ____________________________________________________

5.OPTIONAL: Transfer item responses (Y = YES, S = SOMETIMES, N = NOT YET, X = response missing).

Communication

Gross Motor

Fine Motor

Problem Solving

Personal-Social

P101140700	Ages & Stages Questionnaires®, Third Edition (ASQ-3™), Squires & Bricker
	© 2009 Paul H. Brookes Publishing Co. All rights reserved.

Get Asq 14 Month Questionnaire PDF Form

Form Characteristics

Fact Name	Details
Age Range	This questionnaire is designed for babies aged from 13 months, 0 days to 14 months, 30 days.
Purpose	The ASQ 14 Month Questionnaire aims to identify developmental milestones in communication, gross motor, fine motor, problem-solving, and personal-social skills.
Completion Instructions	Respondents should fill out the form using black or blue ink, and answer legibly for clarity.
Response Options	Each activity in the questionnaire can be marked as "Yes," "Sometimes," or "Not Yet," depending on the baby's ability.
Feedback Space	The form includes space for additional comments, allowing parents or guardians to express any concerns regarding the baby’s development.
Submission Timeline	It is essential to return the completed questionnaire within the time frame specified on the form to ensure timely evaluation.
Resource Origin	The ASQ 14 Month Questionnaire is part of the Ages & Stages Questionnaires®, Third Edition, created by Squires & Bricker.

Guidelines on Utilizing Asq 14 Month Questionnaire

Completing the ASQ 14 Month Questionnaire is a crucial step in tracking your baby's development. After filling out the form, you will be asked to submit it to the appropriate healthcare professional or program. Your responses will be used to assess your baby's developmental milestones and inform any necessary actions or resources for support.

Use only black or blue ink to fill out the form.
Print the date the questionnaire is being completed.
Provide your baby's first name, middle initial, and last name.
Indicate your baby's gender and date of birth. If applicable, specify the number of weeks your baby was born prematurely.
Fill in your details: your first name, middle initial, last name, and your relationship to the baby, such as parent or guardian.
Complete your contact information including street address, city, state, ZIP or postal code, country, and telephone numbers.
Provide your email address if applicable.
List the names of anyone assisting with the questionnaire.
Fill out the Baby ID number and the age at which the questionnaire is administered in months and days.
If your baby was premature, include the adjusted age in months and days.
Indicate the program name and program ID number as required.
Read each section carefully and try each activity with your baby before marking a response.
For each activity described, circle whether your baby does it regularly, sometimes, or not yet.
Use the space provided to note any additional comments or concerns.
Ensure the questionnaire is submitted by the indicated return date.

What You Should Know About This Form

What is the Ages & Stages Questionnaires® 14 Month Questionnaire?

The Ages & Stages Questionnaires® 14 Month Questionnaire is a valuable tool designed to evaluate the developmental progress of babies aged 13 months to 14 months and 30 days. It consists of a series of questions that assess various areas of development, including communication, gross motor skills, fine motor skills, problem-solving abilities, and personal-social skills. The goal is to identify any potential developmental delays and ensure that children are on track for their age.

Who should complete the ASQ 14 Month Questionnaire?

This questionnaire should be filled out by the child's parent or guardian, though it can also involve input from teachers or childcare providers. It's important that the person completing the form is familiar with the child's abilities and routines so that they can provide accurate responses regarding the child's development.

How should I fill out the questionnaire?

When completing the questionnaire, it is essential to use black or blue ink and write clearly. Each question is accompanied by options for answering: "yes," "sometimes," or "not yet." You should first try each activity with your child. This can make the process enjoyable for both of you and can yield more accurate answers about what your child is capable of doing. Consider giving it a fun twist to maintain engagement!

What if my baby is not cooperative during the assessment?

It's common for toddlers to be uncooperative. If your baby seems uninterested or refuses to perform certain tasks, try again at a different time, ideally when your child is more rested and comfortable. If your child can complete a task but is reluctant to do so, you can still mark "yes" for that activity.

What happens if my baby was born prematurely?

If your baby was born three or more weeks early, it's important to use their adjusted age when filling out the ASQ. The adjusted age accounts for the amount of time the baby was in the womb before birth, allowing for a more accurate assessment of development. You'll find a space on the questionnaire to indicate weeks premature, which helps ensure that interpretations of the results are developmentally appropriate.

How will the results be used?

The completed questionnaire will provide insight into your child's development. If there are areas of concern or if your child's development appears to be delayed, you might be referred to additional resources or professionals for further evaluation. The goal is to ensure your child receives the support they need as they grow.

How do I return the completed questionnaire?

After filling out the questionnaire, it should be returned as directed on the form. There will be a specific deadline mentioned for the submission, so keeping track of this date is crucial. Whether you send it via mail or hand it in at a designated location, make sure it reaches the appropriate person in a timely manner.

Common mistakes

Completing the ASQ 14 Month Questionnaire is crucial for tracking your baby's developmental milestones. However, many people make mistakes that can affect the results. One common mistake is not involving the baby in the activities described. Many parents forget to try the activities with their baby before marking a response. This can lead to inaccurate answers, as the responses should reflect the baby's actual abilities rather than the parent's assumptions. It’s important to engage actively with your baby to get the most reliable information.

Another frequent error occurs with the age calculations. Some individuals fail to adjust their baby's age if they were born prematurely. The questionnaire requires the adjusted age to provide an accurate assessment. Marking the wrong age can mislead the evaluation of the baby’s developmental progress. Parents must be mindful to use the adjusted age if their baby was born early to ensure clear understanding of developmental expectations.

Additionally, using improper writing instruments can pose a challenge. The instructions specify that only black or blue ink should be used. When other colors are used, such as red or green, this can create confusion for those reviewing the answers. Ensuring that only the recommended ink is utilized minimizes the risk of errors or misinterpretation of responses.

Finally, neglecting to fill out the personal information section thoroughly can lead to delays or miscommunication. Some parents may omit critical information like their relationship to the baby or contact details. This information is vital for follow-up and analysis. Completing this section carefully can facilitate better support and guidance regarding the baby's development. Ensuring these details are filled out correctly helps streamline any future assistance you may need.

Documents used along the form

The Ages & Stages Questionnaires® (ASQ) are valuable tools used in early childhood development assessments. When utilizing the ASQ 14 Month Questionnaire form, there are several other forms and documents that may accompany it to provide a comprehensive evaluation of a child's development. Below is a list of related documents frequently used in conjunction with the ASQ processes.

ASQ Completion Instructions: This document provides detailed guidance on how to complete the ASQ forms effectively, ensuring accurate results.
ASQ Parent Feedback Form: After completion of the ASQ, this form allows parents to share their impressions and experiences regarding the process and questions.
Developmental Milestones Checklist: This checklist outlines key developmental milestones for various ages, helping parents and caregivers track a child's growth over time.
Follow-Up Referral Form: Should concerns arise during the ASQ evaluation, this document facilitates necessary referrals for further evaluation or intervention by specialists.
ASQ Scoring Sheet: This sheet assists in the scoring of responses from the ASQ forms, helping to quantify developmental progress and identify areas for concern.
Parent Survey on Communication: This survey gathers more specific information about a child's communication habits and interactions with caregivers.
Child Development Observation Form: Caregivers can use this form to record observations of a child's play and interactions, providing additional insights into their development.
Service Provider Contact Information: This document lists contacts for local services and resources that can assist families in accessing additional support.
Early Intervention Program Enrollment Form: If further assistance is needed, this form allows families to enroll their child into developmental programs designed for early intervention.
Confidentiality Agreement: This document ensures that all personal information collected during the assessment process remains confidential and secure.

These accompanying documents support the ASQ process, helping families and providers to create a comprehensive understanding of each child’s development and any necessary next steps. Each document plays a role in facilitating effective communication and follow-up tailored to individual needs.

Similar forms

ASQ-3 Questionnaire: The Ages & Stages Questionnaire-3 is also designed for assessing the development of children. Like the ASQ 14 Month Questionnaire, it uses a similar format with age-specific questions focused on key developmental areas such as communication, gross motor, fine motor, problem-solving, and personal-social skills.
Denver Developmental Screening Test: This tool screens for developmental delays in children from birth through age 6. It shares a similar purpose with the ASQ 14 Month Questionnaire, assessing motor skills, language, and personal-social skills, using a series of tasks to monitor development.
Battelle Developmental Inventory: The Battelle is a comprehensive assessment tool that evaluates developmental needs in infants and toddlers. Much like the ASQ 14 Month Questionnaire, it examines various skill areas through caregiver responses and specific tasks.
Parent's Evaluation of Developmental Status (PEDS): PEDS is a screening tool that allows parents to evaluate their child’s development. Similar to the ASQ 14 Month Questionnaire, it encourages parent involvement and focuses on communication and social capabilities.
Bayley Scales of Infant and Toddler Development: This assessment measures developmental functioning in infants and toddlers. It is akin to the ASQ 14 Month Questionnaire as it covers developmental milestones across communication, motor skills, and cognition, requiring input from caregivers.

Dos and Don'ts

Do complete the questionnaire using black or blue ink.
Do print clearly to ensure your responses can be read easily.
Do try the activities with your baby before marking your response.
Do make the filling process enjoyable for both you and your baby.
Do ensure your baby is well-fed and rested before starting.
Don’t rush through the questionnaire; take your time with each section.
Don’t forget to return the completed questionnaire by the deadline.

Misconceptions

Misconception 1: The ASQ 14 Month Questionnaire is only for developmental experts.

This questionnaire is intended for parents and caregivers. It helps them observe their child’s developmental milestones. Anyone familiar with the child's behavior can complete it.

Misconception 2: A low score indicates my child is not normal.

A low score does not mean a child has developmental delays. It simply highlights areas where the child may need more support. Development varies widely among children.

Misconception 3: All questions must be answered positively.

Misconception 4: The questionnaire can only be completed once.

You can retake the questionnaire at different times. Your child’s abilities will evolve as they grow. Continuous observation can provide a fuller picture of their development.

Misconception 5: The ASQ 14 Month Questionnaire is a test.

This is not a pass or fail test. It is a helpful tool for identifying strengths and areas that might need attention. The goal is to support developmental growth.

Misconception 6: You should only fill it out if concerns arise.

Parents are encouraged to complete this questionnaire even if they have no concerns. It can serve as a valuable way to track development and celebrate achievements.

Misconception 7: Responses must be filled in perfectly.

Completeness and accuracy are important, but perfection is not required. The questionnaire is a guide, and honest, thoughtful responses are what matter most.

Key takeaways

Here are some key takeaways about the ASQ 14 Month Questionnaire:

The form is designed for babies aged 13 months to 14 months and 30 days.
Use only black or blue ink to fill out the form, and print clearly.
Before marking responses, try each activity with your baby to see if they can do it.
Make completing the questionnaire a fun game for you and your baby.
Ensure your baby is well-rested and fed, as this can affect their performance.
Remember that toddlers might not always cooperate. Be patient and try activities multiple times.
Fill in the date when the ASQ was completed for reference.
List any other people who helped you fill out the questionnaire.
After completing the questionnaire, return it by the specified deadline.
The questionnaire includes various sections, such as communication and gross motor skills, to assess your baby’s development.

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