Form 0920- Permission Form Checklist

Attachment N

Permission Form Checklist

Form Approved

OMB No. 0920-xxxx

Expiration Date: xx/xx/xxxx

Permission Form Checklist for Schools Requiring Active Permission

School ID: ______________

School Name: ___________________

Class ID: _____________

Teacher Name: _______________

Date of First Survey Administration:___________________

Date of Second Survey Administration: ___________________

Permission Form Distribution	Date
Date permission form distributed (should be about 3 weeks before the survey is given to students)
Date students were first reminded to bring back forms (hand out new forms if needed) (should be about 2 weeks before the survey is given to students)
Date students were reminded again to bring back forms (hand out new forms if needed) (should be about 3 days-1 week before the survey is given to students)

	Student name or other identfier	Put an “X” if active permission is granted	Put an “X” if either no permission form was returned OR active permission was not granted (student may not take the survey)
Ex.	Johnny Smith	X
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Public reporting burden for this collection of information is estimated to average 15 minutes per response, including the time for reviewing instructions, searching existing data sources, gathering and maintaining the data needed, and completing and reviewing the collection of information. An agency may not conduct or sponsor, and a person is not required to respond to a collection of information unless it displays a currently valid OMB control number. Send comments regarding this burden estimate or any other aspect of this collection of information, including suggestions for reducing this burden to CDC/ATSDR Reports Clearance Officer; 1600 Clifton Road NE, MS D-74, Atlanta, GA 30333; Attn: OMB-PRA (0920-xxxx)

Form Approved

OMB No. 0920-xxxx

Expiration Date: xx/xx/xxxx

Permission Form Checklist for Schools Requiring Passive Permission

School ID: ______________

School Name: ___________________

Class ID: _____________

Teacher Name: _______________

Date of First Survey Administration:___________________

Date of Second Survey Administration: ___________________

Permission Form Distribution	Date
Date permission form distributed (should be about 3 weeks before the survey is given to students)
Date students were first reminded to bring back forms (hand out new forms if needed) (should be about 2 weeks before the survey is given to students)
Date students were reminded again to bring back forms (hand out new forms if needed) (should be about 3 days-1 week before the survey is given to students)

	Student name or other identfier	Put an “X” if the student’s parent or guardian opts the student out (student may not take the survey)
Ex.	Johnny Smith	X
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Public reporting burden for this collection of information is estimated to average 15 minutes per response, including the time for reviewing instructions, searching existing data sources, gathering and maintaining the data needed, and completing and reviewing the collection of information. An agency may not conduct or sponsor, and a person is not required to respond to a collection of information unless it displays a currently valid OMB control number. Send comments regarding this burden estimate or any other aspect of this collection of information, including suggestions for reducing this burden to CDC/ATSDR Reports Clearance Officer; 1600 Clifton Road NE, MS D-74, Atlanta, GA 30333; Attn: OMB-PRA (0920-xxxx)