Healthy Students Questionnaire Parent Consent Forms

Healthy Students Questionnaire

Active Parent Consent Form (for children ages 9-17)

Dear [parent or guardian],

Our school has been selected to participate in the Healthy Students Questionnaire to see if our school health policies, practices, and programs are helping students be healthy. This project is sponsored by the U.S. Centers for Disease Control and Prevention (CDC).

Students will be asked to complete a questionnaire that takes about 20 minutes. The questionnaire will ask students about their eating and exercise habits, the health support they receive from school, how they feel in school, and their grades.

The questionnaire is anonymous and will protect your child’s privacy. Students will not be asked to provide their names on the questionnaire. Also, no school or student will ever be mentioned by name in published reports. No student will be identifiable based on the answers on any questionnaire.

Your child will get no immediate benefit from taking part in the questionnaire. However, the results of this questionnaire may help your child and other children in the future if the results help improve school health policies and practices.

Doing this questionnaire will cause little to no risk to your child. We would like all selected students to take part in the project, but the questionnaire is voluntary. No action will be taken against the school, you, or your child if your child does not participate. Students can skip any questions they do not wish to answer. In addition, students may stop participating in the questionnaire at any point without penalty.

If you have questions about this questionnaire please contact the evaluation team at 2302evaluation@icf.com. For questions regarding your rights related to this questionnaire you can contact ICF Institutional Review Board (IRB) chair at irb@icf.com.

Please discuss the project with your child, read the section below, check one box, and sign the form. Thank you!

I have read this form and know what the questionnaire is about.

Please check one box:

YES, my child can participate in this questionnaire.

• NO, my child may not participate in this questionnaire.

Parent or guardian’s signature __________________________________

Child’s name: __________ Grade: _________

Date:_____________________

Passive Parent Consent Form (for children ages 9-17) 

Dear [parent or guardian],  

Our school has been selected to participate in the Healthy Students Questionnaire to see if our school health policies, practices, and programs are helping students be healthy. This project is sponsored by the U.S. Centers for Disease Control and Prevention (CDC).   

Students will be asked to complete a questionnaire that takes about 20 minutes. The questionnaire will ask students about their eating and exercise habits, the health support they receive from school, how they feel in school, and their grades. 

The questionnaire is anonymous and will protect your child’s privacy. Students will not be asked to provide their names on the questionnaire. Also, no school or student will ever be mentioned by name in published reports. No student will be identifiable based on the answers on any questionnaire. 

Your child will get no immediate benefit from taking part in the questionnaire. However, the results of this questionnaire may help your child and other children in the future if the results help improve school health policies and practices.  

Doing this questionnaire will cause little to no risk to your child. We would like all selected students to take part in the project, but the questionnaire is voluntary. No action will be taken against the school, you, or your child if your child does not participate. Students can skip any questions they do not wish to answer. In addition, students may stop participating in the questionnaire at any point without penalty.  

If you have questions about this questionnaire please contact the evaluation team at 2302evaluation@icf.com. For questions regarding your rights related to this questionnaire you can contact ICF Institutional Review Board (IRB) chair at [contractor email].   

Please read the section below and check the box only if you DO NOT want your child to participate. Thank you! 

 

I have read this form and know what the questionnaire is about.  

NO, my child may not participate in this questionnaire.  

Parent or guardian’s signature __________________________________ 

Child’s name: __________   Grade: _________  

Date:_____________________