Summary of School Arrangements Forms

VIRTUAL ADMINISTRATION
SUMMARY OF SCHOOL ARRANGEMENTS (SSA)
2021 NATIONAL YOUTH TOBACCO SURVEY
[MDR_#]
Please review the information below. If there are any changes, please call us toll-free at 1-800-287-1815 to make certain
these changes are recorded. Thank you in advance for your time.
School Name:
School Address:

[School Name]
[School Address]
[City, ST ZIP]

District Name:
School Phone:

Name and Phone of School Contact:
[Contract Name, Title, Phone]

Name and Phone of Principal:
[Principal Name, Phone]
Scheduled Date(s) of Data Collection:
[Day, Date]

I.

[District Name]
[School Phone]

Name and Phone of Technical Assistance Provider (TAP):
[TAP Name, Phone]

FOR TEACHERS – IMPORTANT INFORMATION – Please READ

This information is designed to guide/aide you in the survey administration process. On the day of the survey,
participating students will need an internet-connected device, either provided by the school or a personal device. All
other materials you need to administer the web-based survey have been provided electronically by the school contact
(listed above).
If you have questions, please reach out to your school’s point of contact or your school’s assigned Technical Assistance
Provider (highlighted above). Thank you for your part in making the survey a success in your virtual classroom(s)!
As soon as possible:
• Review the list of classes that have been randomly selected to participate.
• Log-in to nyts.cdc.gov to access your teacher portal, using the Teacher Code listed in the table below.
• Watch the first of two brief 2-minute videos (“Pre-survey” video) for pertinent information prior to the survey
administration.
NOTE: If you have multiple classes selected, each class will have a different Teacher Code. However, you only
need to watch the video once.
Teacher Name
[Teacher Name]
[Teacher Name]
[Teacher Name]
[Teacher Name]
[Teacher Name]
[Teacher Name]
[Teacher Name]
[Teacher Name]

Type of Class
[Class]
[Class]
[Class]
[Class]
[Class]
[Class]
[Class]
[Class]

Period

Teacher Code

[PD]
[PD]
[PD]
[PD]
[PD]
[PD]
[PD]
[PD]

[CODE]
[CODE]
[CODE]
[CODE]
[CODE]
[CODE]
[CODE]
[CODE]

On the day of the survey administration:
• Log-in to nyts.cdc.gov using the Teacher Code above to watch the 2-minute “Day of Survey” video.
• Determine who can take the survey based on the return of the parental permission forms.
• Provide students taking the survey with the survey URL and the Classroom Access Code associated with your
class as noted below. NOTE: this is different than your Teacher Code in the table above. If you have multiple
classes selected, each class will have a different Classroom Access Code.

STUDENT SURVEY URL: nyts.cdc.gov

Teacher Name
[Class]
[Class]
[Class]
[Class]
[Class]
[Class]
[Class]
[Class]

[Teacher Name]
[Teacher Name]
[Teacher Name]
[Teacher Name]
[Teacher Name]
[Teacher Name]
[Teacher Name]
[Teacher Name]
•

•

Class

Period

Classroom Access Code

[PD]
[PD]
[PD]
[PD]
[PD]
[PD]
[PD]
[PD]

[CODE]
[CODE]
[CODE]
[CODE]
[CODE]
[CODE]
[CODE]
[CODE]

Log-in to nyts.cdc.gov using the Teacher Code (from the blue table above) and complete the Class Enrollment
form. If you have more than one selected class, please complete the form for each class using the appropriate
code.
For eligible students who are absent on the day of the survey, please provide them with the student survey
URL and Classroom Access Code when they return to class and encourage them to complete the survey.

II. SELECTED CLASS SECTIONS:
Collection
Date
[Date]
[Date]
[Date]
[Date]
[Date]
[Date]
[Date]
[Date]

Grade
[GR]
[GR]
[GR]
[GR]
[GR]
[GR]
[GR]
[GR]

Name of Teacher
[Teacher Name]
[Teacher Name]
[Teacher Name]
[Teacher Name]
[Teacher Name]
[Teacher Name]
[Teacher Name]
[Teacher Name]

Type of Class
[Class]
[Class]
[Class]
[Class]
[Class]
[Class]
[Class]
[Class]

No. of
Students
[#]
[#]
[#]
[#]
[#]
[#]
[#]
[#]

Period
[PD]
[PD]
[PD]
[PD]
[PD]
[PD]
[PD]
[PD]

III. PARENTAL PERMISSION FORMS:
Type:

[Active/Opt-out]

Other Language Forms Needed:

Distribution Method:

[Paper/Electronic]

Notes:

[Notes]

[Permission form distribution message specific to Active or Opt-out]

IV. ADDITIONAL INFORMATION:

[Notes]

Start
Time
[Time]
[Time]
[Time]
[Time]
[Time]
[Time]
[Time]
[Time]

End
Time
[Time]
[Time]
[Time]
[Time]
[Time]
[Time]
[Time]
[Time]

IN PERSON ADMINISTRATION
SUMMARY OF SCHOOL ARRANGEMENTS (SSA)
2021 NATIONAL YOUTH TOBACCO SURVEY
[MDR_#]
Please review the information below. If there are any changes, please call us toll-free at 1-800-287-1815 to make certain
these changes are recorded. Thank you in advance for your time.
School Name:
School Address:

[School Name]
[School Address]
[City, ST ZIP]

District Name:
School Phone:

[District Name]
[School Phone]

Name and Phone of School Contact:
[Contract Name, Title, Phone]

Name and Phone of Principal:
[Principal Name, Phone]
Scheduled Date(s) of Data Collection:
[Day, Date]

Name and Phone of Technical Assistance Provider (TAP):
[TAP Name, Phone]

II. FOR TEACHERS – IMPORTANT INFORMATION – Please READ
This information is designed to guide/aide you in the survey administration process. On the day of the survey,
participating students will need an internet-connected device, either provided by the school or a personal device. All
other materials you need to administer the web-based survey have been provided (student sign-in cards, earbuds).
If you have questions, please reach out to your school’s point of contact (listed above) or your school’s assigned
Technical Assistance Provider (highlighted above). Thank you for your part in making the survey a success in your
classroom(s)!
As soon as possible:
• Review the list of classes that have been randomly selected to participate.
• Log-in to nyts.cdc.gov to access your teacher portal, using the Teacher Code listed in the table below.
• Watch the first of two brief 2-minute videos (“Pre-survey” video) for pertinent information prior to the
survey administration.
• We have provided earbuds so that you may hear the audio without disturbing your class.
NOTE: If you have multiple classes selected, each class will have a different Teacher Code. However, you only
need to watch the video once.
Teacher Name
[Teacher Name]
[Teacher Name]
[Teacher Name]
[Teacher Name]

Type of Class
[Class]
[Class]
[Class]
[Class]

Period
[PD]
[PD]
[PD]
[PD]

Teacher Code
[CODE]
[CODE]
[CODE]
[CODE]

On the day of the survey administration:
• Log-in to nyts.cdc.gov using the Teacher Code above to watch the 2-minute “Day of Survey Video.”
• Determine who can take the survey based on the return of the parental permission forms.
• Distribute the student sign-in cards and earbuds, one for each student. Student instructions are printed on
the cards.
• Log-in to nyts.cdc.gov using the Teacher Code and complete the Class Enrollment form. If you have more
than one selected class, please log in and complete the information for each class using the appropriate
code.
• For eligible students who are absent on the day of the survey, please provide them with a student sign-in
card and earbuds when they return to class and encourage them to complete the survey.

II. SELECTED CLASS SECTIONS:
Collection
Date
[Date]
[Date]
[Date]
[Date]

Grade
[GR]
[GR]
[GR]
[GR]

Name of Teacher
[Teacher Name]
[Teacher Name]
[Teacher Name]
[Teacher Name]

Type of Class
[Class]
[Class]
[Class]
[Class]

No. of
Students
[#]
[#]
[#]
[#]

Period
[PD]
[PD]
[PD]
[PD]

III. PARENTAL PERMISSION FORMS:
Type:

[Active/Opt-out]

Other Language Forms Needed:

Distribution Method:

[Paper/Electronic]

Notes:

[Notes]

[Permission form distribution message specific to Active or Opt-out]

IV. ADDITIONAL INFORMATION:

[Notes]

Start
Time
[Time]
[Time]
[Time]
[Time]

End
Time
[Time]
[Time]
[Time]
[Time]