attach 4 (2)

Attachment 4: Parent Consent

PASSIVE PARENTAL PERMISSION FORM Class ID _____

Our school is participating in the Health Behaviors in School-Age Children (HBSC) survey. In the United States, this survey is sponsored by the National Institute of Child Health and Human Development (NICHD) of the National Institutes of Health (NIH) and the Maternal and Child Health Bureau (MCHB) of the Health Resources and Services Administration (HRSA).

The HBSC survey will gather information about nutrition, dieting practices, physical activity, injuries, violence, relationships with family and friends, perceptions of school as a supportive environment, alcohol and tobacco use, drug use, and the communities in which students live.

The information collected from school children in the United States as a group will be compared with similar information collected from school children in 40 other nations. The survey is used to help set national priorities for school and youth programs as well as to monitor the progress of these programs. The survey is authorized by Section 448 of the Public Health Service Act. The HBSC survey has been approved by State and local school officials. The survey has extensive support from national organizations, such as the National PTA.

Completing this paper and pencil survey poses no or minimal risk to your child. Survey procedures will protect your child's privacy and allow for anonymous participation. No school or student will ever be mentioned by name in a report of the results. It is very important that all selected students participate. However, the decision to participate is voluntary.

Please read the section below. If you do not want your child to participate, check the box below, sign and return this form to the school within three days. If we do not receive a completed form, your child will be asked to complete the survey. Please see the other side of this form for additional information. If your child=s teacher or principal cannot answer your questions about the survey, you may call Ms. Mary Ann D’Elio of The CDM Group at toll-free (888) 246-9626. Thank you for your cooperation.

Printed Name of Student:________________________________ Grade:____________

I have read and understand this form concerning the Health Behaviors in School-age Children Survey. I do not want my child to participate in the survey.

[ ] My child does not have my permission to participate.

Parent's Signature:____________________________________________ Date:_____________

Phone Number:_______________________

ACTIVE PARENTAL PERMISSION FORM Class ID ______

Our school is participating in the Health Behaviors in School-Age Children (HBSC) survey. In the United States, this survey is sponsored by the National Institute of Child Health and Human Development (NICHD) of the National Institutes of Health (NIH) and the Maternal and Child Health Bureau (MCHB) of the Health Resources and Services Administration (HRSA).

The HBSC survey will gather information about nutrition, dieting practices, physical activity, injuries, violence, relationships with family and friends, perceptions of school as a supportive environment, alcohol and tobacco use, drug use, and the communities in which students live.

The information collected from school children in the United States as a group will be compared with similar information collected from school children in 40 other nations. The survey is used to help set national priorities for school and youth programs as well as to monitor the progress of these programs. The survey is authorized by Section 448 of the Public Health Service Act. The HBSC survey has been approved by State and local school officials. The survey has extensive support from national organizations, such as the National PTA.

Completing this paper and pencil survey poses no or minimal risk to your child. Survey procedures will protect your child's privacy and allow for anonymous participation. No school or student will ever be mentioned by name in a report of the results. It is very important that all selected students participate. However, the decision to participate is voluntary.

Please read the section below. Check the appropriate box and return the form to the school within three days. Please see the other side of this form for additional information. If your child=s teacher or principal cannot answer your questions about the survey, you may call Ms. Mary Ann D’Elio of The CDM Group toll-free at (888) 246-9626. Thank you for your cooperation.

Printed Name of Student:________________________________ Grade:____________

I have read and understand this form concerning the Health Behaviors in School-age Children Survey. [Check one below]

[ ] My child has my permission to participate.

[ ] My child does not have my permission to participate.

Parent's Signature:____________________________________________ Date:_____________

Phone Number:_______________________

My signature below shows that I agree to fill-out the Health Behaviors in School-age Children Survey. If I do not sign this form, it means I do not agree to participate.

Student=s Signature:_____________________________________________ Date:_____________