Healthy Student Questionnaire 18+ Consent Form

Healthy Students Questionnaire

Student Consent Form (for students 18+)

Dear Student,

Your school has been selected to participate in the Healthy Students Questionnaire. This project is sponsored by the U.S. Centers for Disease Control and Prevention (CDC).

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

We will not ask your name, so the answers you provide on the questionnaire will be private.

You will get no immediate benefit from taking part in the questionnaire. However, the results of this questionnaire may help you and other students in the future if they lead to school health improvements. Participating in the questionnaire is not expected to have any risks.

The questionnaire is voluntary and you can skip any questions you do not wish to answer. No action will be taken against you or your school if you do not participate. In addition, you 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 survey you can contact ICF Institutional Review Board (IRB) at irb@icf.com. 

After reading the form, please review the section below, check one box, and sign the form. Please sign or initial the form if you agree to take part in the questionnaire. Thank you!

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

Please check one box:

• YES, I would like to participate in this questionnaire.

• NO, I would not like to participate in this questionnaire.

Your signature __________________________________

Your name: _________________ Grade: _________ Date:_____________________