Can the ASQ-18M be signed electronically?

Yes. Electronic signatures on ASQ-18M forms are generally valid under the ESIGN Act and UETA when intent, consent, attribution, and record retention are satisfied. For caregiver-facing records, provide ESIGN consumer disclosure and document the method of authentication and consent.

Do caregivers need to receive a consumer disclosure?

Yes. When using electronic records for consumer-facing healthcare forms, the ESIGN Act requires a clear disclosure explaining rights to paper copies, how to withdraw consent, and demonstration that the caregiver can access electronic records.

Is HIPAA compliance required for e-signatures?

Yes. If ASQ-18M data contains protected health information and a vendor stores or transmits it, HIPAA applies. Execute a Business Associate Agreement with any third-party eSignature vendor and ensure technical safeguards per 45 CFR §164.308 and §164.312.

When should I refer to early intervention?

Refer when scoring indicates concern in one or more developmental domains, when caregivers report persistent delays, or when clinical judgement suggests evaluation. Timely referral supports access to services; follow local program timelines and document the referral in the medical record.

How long must I retain signed ASQ forms?

Retain signed ASQ-18M forms according to applicable law: follow HIPAA’s six-year requirement for healthcare records (45 CFR §164.530(j)) and maintain records per federal or state program rules; check state-specific retention periods for early intervention records.

What if caregiver lacks internet access?

Offer paper completion during visits or an in-clinic tablet kiosk. If you collect a paper form, scan and upload signed copies to the EHR, or follow local hybrid workflows ensuring secure storage and an auditable record of receipt.

Electronic Signature
Templates
Healthcare
Healthcare ASQ-18M Form

Healthcare ASQ-18M Form

This template is fully customizable. Edit the text, fill out the fields, and send it for signature. Give it a try!

HEALTHCARE ASQ-18M FORM

Instructions: This Ages & Stages Questionnaire (ASQ) 18-month screening is to be completed by the primary caregiver. Answer each item based on the child's typical behavior. Responses are used to identify developmental strengths and concerns and to determine whether follow-up, rescreening, or referral for further assessment is recommended. By signing below the caregiver affirms that the information provided is accurate to the best of their knowledge and consents to this screening and to any necessary exchange of information with health or early intervention providers for care coordination.

Child Information

Child Name:

Date of Birth

Age (months)

Gender: Male Female Other

Home Address

Primary Phone

Primary Language Spoken to Child

Caregiver / Contact

Caregiver Name:

Relationship to Child:

Caregiver Phone

Insurance & Primary Care

Insurance Provider

Policy Number

Group Number

Subscriber / Policyholder Name

Medical History

Current Medications Allergies Prior Surgeries / Hospitalizations Chronic Conditions / Concerns

Pediatrician / Primary Care Provider

Provider Phone

Screening Details

Screening Date:

Screening Site:

Screening Staff Name:

ASQ-18 Month Questionnaire

For each item, indicate the child's typical behavior by selecting one response: Yes / Sometimes / Not yet.

Communication

1. Does your child use at least 6-10 different words when talking?

Yes Sometimes Not yet

2. Does your child point to request or to show things to you?

Yes Sometimes Not yet

3. Does your child use gestures and words together (e.g., points while saying a word)?

Yes Sometimes Not yet

Gross Motor

1. Can your child walk up steps with assistance or by holding a hand?

Yes Sometimes Not yet

2. Does your child stand on one foot briefly or jump in place?

Yes Sometimes Not yet

Fine Motor

1. Can your child pick up small objects using thumb and index finger (pincer grasp)?

Yes Sometimes Not yet

2. Does your child build a tower of 4 or more blocks?

Yes Sometimes Not yet

Problem Solving

1. Does your child find hidden toys (object permanence) when they see you hide them under a blanket?

Yes Sometimes Not yet

2. Can your child complete simple problem-solving tasks like fitting shapes into a sorter?

Yes Sometimes Not yet

Personal-Social

1. Does your child show interest in playing near or with other children?

Yes Sometimes Not yet

2. Can your child feed self with finger foods or use a spoon with some assistance?

Yes Sometimes Not yet

Scoring note: Each domain receives a score based on responses. Scores are used to determine whether results fall in the monitoring, rescreen, or referral ranges. Document below is a summary of scores and follow-up recommendations made by the screening staff.

Scoring Summary & Recommendations

Communication Score

Gross Motor Score

Fine Motor Score

Problem Solving Score

Personal-Social Score

Total Score

Recommended Action (select all that apply):

Continue routine monitoring and activities to support development Rescreen in months Refer for further evaluation (early intervention, audiology, etc.)

Provider Comments / Plan

Consent, Privacy & Authorization

I acknowledge that I have reviewed this screening with the staff and understand the results and recommendations recorded above. I consent to the release and exchange of information regarding this screening to assist with coordination of care and any necessary referrals to early intervention or specialty providers. I understand that the information will be handled in accordance with applicable privacy rules and used only for treatment, care coordination, or authorized program evaluation.

I consent to the ASQ-18M screening and the release/exchange of screening results as described above.

Authorization Expiration Date

Printed Name:

Relationship to Child:

Signature:

Date:

What the Healthcare ASQ-18M Form Is and when it’s used

The Healthcare ASQ-18M Form is a standardized 18-month Ages and Stages Questionnaire used by pediatric and primary care providers to screen child development across communication, gross motor, fine motor, problem solving, and personal-social domains. Completed by caregivers at or near the 18-month well-child visit, the form documents observable milestones, highlights caregiver concerns, and informs referrals to early intervention or specialist evaluation. Completed forms become part of the medical record and support follow-up monitoring, care coordination, and program-level quality measurement.

Why use the Healthcare ASQ-18M Form

The Healthcare ASQ-18M Form helps detect developmental delays early, standardizes screening at the 18-month visit, and creates a consistent record for referrals, care planning, and quality reporting across clinics and programs.

Who completes and relies on the ASQ-18M results

Primary users of the Healthcare ASQ-18M Form include pediatricians, nurse practitioners, early intervention coordinators, and family caregivers involved in routine developmental surveillance.

Pediatric clinicians: incorporate results into well-child visit notes and referrals.
Early intervention staff: use form findings to prioritize evaluations and services.
Caregivers: complete items based on daily observations of the child.

Organizations such as community health centers, early childhood programs, and public health teams often integrate ASQ-18M screening into population health workflows.

Security and privacy considerations for ASQ-18M records

PHI Protection: HIPAA-compliant handling required with BAA if stored electronically.

Data encryption: TLS 1.2/1.3 in transit, AES-256 at rest.

Access controls: Role-based access and audit trails enabled.

Signer authentication: Multi-factor or secure link authentication options.

Retention: Stored per HIPAA and organization policies.

Audit trail: Full timestamp, IP, and action history recorded.

Risks and consequences of incorrect or incomplete ASQ-18M forms

Missed referral: Delayed intervention services

Incorrect age: Wrong milestone norms applied

Incomplete consent: ESIGN disclosures missing for caregivers

PHI exposure: Potential HIPAA violation and fines

Data integrity: Poor recordkeeping affects audits

Legal challenges: Probative value may be reduced

Step-by-step: collecting and documenting the ASQ-18M

Follow these steps to collect, review, and document responses on the Healthcare ASQ-18M Form during the 18-month visit.

01

Prepare form: Provide caregiver with printed or electronic ASQ-18M before visit.
02

Complete items: Caregiver answers items based on typical observation.
03

Score: Follow scoring rubric to identify concerns by domain.
04

Act: Document findings, inform family, and refer as indicated.

Configure your online ASQ-18M workflow

Configure online workflows to collect ASQ-18M responses, authenticate caregivers, and route results into the child’s electronic health record.

Field	Configuration
Form format and delivery options	Fillable PDF, web form, and mobile-friendly option.
Signer authentication and verification options	Email link, SMS code, or KBA if required.
EHR integration and export settings	Export as PDF or structured data (FHIR compatible).
Routing rules, alerts, and assignment	Auto-route to clinician or early intervention coordinator.

Platform and file requirements for electronic collection

Select platforms and file formats compatible with your EHR, mobile devices, and storage systems to streamline ASQ-18M collection.

File formats: PDF, DOCX, and HTML supported.
Integrations: Connects with EHRs, Salesforce, NetSuite.
Access: Mobile apps and browser access available.

Typical electronic signing workflow for the ASQ-18M

This workflow illustrates the typical electronic collection, authentication, and routing for the Healthcare ASQ-18M Form.

Upload: Provider uploads fillable ASQ-18M to the signing platform.
Invite: Send secure signing link or email to caregiver.
Authenticate: Caregiver verifies identity via SMS or email code.
Record: Signed form and audit trail stored in EHR.

Timing: screening, referral, and follow-up windows

Timelines reflect typical screening, documentation, and referral windows following completion of the Healthcare ASQ-18M Form.

Screening age window:

Complete at the 18-month well-child visit; allow some scheduling flexibility.

Immediate actions:

Document concerns and notify caregiver during the visit.

Referral timing:

Initiate referrals promptly; many programs expect contact within weeks.

Evaluation window:

Early intervention eligibility evaluations often occur within 30–60 days.

Follow-up schedule:

Schedule targeted monitoring visits every 3 months when monitoring.

Baseline pricing and feature availability for eSignature vendors

Compare baseline pricing and key feature availability for common eSignature vendors used to collect and sign Healthcare ASQ-18M Forms.

	signNow	DocuSign	Adobe Sign	PandaDoc	HelloSign
Starting Price	$8/user/month billed annually for Business plan	$15/user/month billed annually for standard plans	$14/user/month billed annually for standard plans	$19/user/month billed annually base plan	$15/user/month billed annually per user
Free Trial	7-day free trial with no credit card required	Varies by vendor and plan tier	Varies by vendor and plan tier	Varies by vendor and plan tier	Varies by vendor and plan tier
Bulk Send	Available on higher tiers and Business Premium	Available on comparable business tiers and add-ons	Available on business plans and add-ons	Available on select plans with bulk features	Not generally available across plans
Audit Trail	Full audit trail with timestamps and IP history	Full audit trail and certificate of completion	Full audit trail and certificate of completion	Audit events and history included	Audit trail available but features vary by plan
HIPAA Compliant	Offers HIPAA compliance; BAA available on request	Supports HIPAA; BAA available for qualifying accounts	Supports HIPAA; BAA available for qualifying plans	Not HIPAA-compliant by default; verify with vendor	Not HIPAA-compliant by default; verify with vendor
Envelope Cap	No envelope cap; unlimited sends on paid plans	Limits to 100 envelopes per user per year on some tiers	Varies by plan and vendor limits	Varies by plan and vendor limits	Varies by plan and vendor limits

Common mistakes when preparing or signing ASQ-18M forms

Skipping caregiver consent steps or failing to provide the ESIGN consumer disclosure can invalidate electronic caregiver authorization for sharing PHI.
Incomplete item marking, erased answers, or ambiguous marks may produce incorrect scores and lead to under- or over-referral.
Recording the wrong birth date or name causes mismatches with EHR and may prevent linking to previous records for interventions.
Failing to secure electronic storage, encrypt data, or sign a BAA with vendors risks HIPAA noncompliance and regulatory penalties.

Practical steps to improve accuracy and compliance

Adopt consistent processes to improve accuracy and legal defensibility of ASQ-18M screening and signed records.

Standardize intake and documentation procedures

Use a single form version, train staff on scoring rules, and require electronic signature capture with audit trail. Standardization reduces scoring errors, accelerates referrals, and simplifies longitudinal tracking across visits and providers.

Verify caregiver identity and record consent

Confirm caregiver identity using documented methods, provide ESIGN consumer disclosure when using electronic records, and record consent method. Clear consent practices maintain legal validity and permit secure information sharing with early intervention services when needed.

Integrate ASQ-18M with EHRs and reporting

Map form fields to discrete EHR data elements or FHIR resources, automate export of scores and alerts, and schedule follow-up tasks. Structured integration reduces manual transcription errors and supports quality measurement and population health analytics.

Secure storage and retention policy enforcement

Encrypt stored forms, set retention schedules aligned with HIPAA and state rules, and maintain accessible audit logs. Periodically review vendor BAAs and revoke third-party access when users leave or contracts change to reduce data exposure.

Frequently asked questions about the Healthcare ASQ-18M Form

Common questions about completing, signing, and storing the Healthcare ASQ-18M Form are answered below for clinicians and caregivers.

Need help? Contact support

Can the ASQ-18M be signed electronically?
Yes. Electronic signatures on ASQ-18M forms are generally valid under the ESIGN Act and UETA when intent, consent, attribution, and record retention are satisfied. For caregiver-facing records, provide ESIGN consumer disclosure and document the method of authentication and consent.
Do caregivers need to receive a consumer disclosure?
Yes. When using electronic records for consumer-facing healthcare forms, the ESIGN Act requires a clear disclosure explaining rights to paper copies, how to withdraw consent, and demonstration that the caregiver can access electronic records.
Is HIPAA compliance required for e-signatures?
Yes. If ASQ-18M data contains protected health information and a vendor stores or transmits it, HIPAA applies. Execute a Business Associate Agreement with any third-party eSignature vendor and ensure technical safeguards per 45 CFR §164.308 and §164.312.
When should I refer to early intervention?
Refer when scoring indicates concern in one or more developmental domains, when caregivers report persistent delays, or when clinical judgement suggests evaluation. Timely referral supports access to services; follow local program timelines and document the referral in the medical record.
How long must I retain signed ASQ forms?
Retain signed ASQ-18M forms according to applicable law: follow HIPAA’s six-year requirement for healthcare records (45 CFR §164.530(j)) and maintain records per federal or state program rules; check state-specific retention periods for early intervention records.
What if caregiver lacks internet access?
Offer paper completion during visits or an in-clinic tablet kiosk. If you collect a paper form, scan and upload signed copies to the EHR, or follow local hybrid workflows ensuring secure storage and an auditable record of receipt.

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