Att K_Passive Parent Consent Form

Attachment K

Passive Parental Permission Form

NOTE: This form only needs to be signed and returned if you do NOT want your child to participate.

Our school is taking part in a research study to test the reliability of the 2021 National Youth Risk Behavior Survey. This survey is sponsored by the Centers for Disease Control and Prevention (CDC) and being conducted by Westat, a social science research firm in Rockville, MD. The purpose of the study is to establish the reliability of data collected by the YRBS. To do that, students will take the survey two times, two weeks apart, to determine if they are answering questions on the survey the same way each time. CDC is conducting this study to develop better questionnaires in the future. Reliable data is important because the results of these surveys are used by schools, districts, and the CDC to improve health-related education, policies, and programs.

For this research study, students will be asked to fill out a survey that takes about 35 minutes to complete. The survey will ask about behaviors related to nutrition, physical activity, injuries, violence, and tobacco, alcohol, and other drug use. It will also ask about sexual behaviors that could lead to pregnancy and sexually transmitted diseases, including HIV. Students will be asked to fill out the same survey again approximately two weeks later. The second survey will also take about 35 minutes to complete. Although there are no direct benefits to students, the results of this study will be very helpful in determining whether to make changes to the questionnaire.

Completing this paper and pencil survey for the study will cause little or no risk to your child. The only potential risk is that some students might find certain questions to be sensitive. The survey has been designed to protect your child’s privacy. Students will not put their names on the survey. Student names will only be attached to a blank envelope containing a blank survey that will be used for the second survey administration. This envelope will never contain a completed survey. Also, no school or student will ever be mentioned by name in a report of the results, nor will your child’s answers or anything else your child writes on the surveys ever be shared with you, their teachers, school administrators, or local authorities. For the survey results to be accurate, it is important that all students, regardless of whether they have engaged in health-risk behaviors, are given an opportunity to participate in the survey.

Completing the survey is voluntary. No action will be taken against the school, you, or your child if your child does not take the survey. Students may skip any questions they do not wish to answer. In addition, students may stop taking the survey at any point without penalty. A process will be in place to help students who are uncomfortable with the content of the survey and want to stop taking the survey. A list of available support resources at the school or in the community will be given to all students once they have completed the survey. If you would like to see the survey, a copy is available [identify location or name and contact information of whom the parent should call].

Please read the other side of this form for more facts about the survey and study. Then, please complete the section below and return it to the school within 3 days only if you do not want your child to take part in the study. Please note that this permission form is being distributed once for both survey administrations. If you have additional questions about the survey or study that your child’s teacher or principal cannot answer, please call [name of Westat contact] at [phone number]. Thank you.

___________________________________________________________________________

Please complete this section of the form only if you do not want your child to participate in the study.

Student’s name: ___________________________________________ Grade: ______________

I have read this form and know what the study is about. I understand that this permission form is for both survey administrations.

[ ] NO, my child may not take part in this study.

Parent’s signature: ________________________________________ Date: _________________

Phone number: __________________________________________