Healthy Schools Questionnaire Consent Form

Healthy Schools Questionnaire

Consent Form

The [recipient organization] is receiving funds from the Centers for Disease Control and Prevention (CDC) to help improve student health in school and out-of-school-time settings. Your school is within a school district that is part of this funded program.

The purpose of this survey is to learn how schools are implementing evidence-based physical activity, nutrition, and school health services practices and programs for students and advancing health equity during the current [insert year range, e.g., 2024-2025] school year. 

This survey should take about 30 minutes to complete. The survey should be completed by the school principal or a school staff member designated by the principal who is familiar with school health activities in your school. The person completing the survey should reach out to other school staff as needed to respond accurately to all questions in the survey.

Participation in this survey is voluntary and you may choose not to respond to any question. If you choose not to participate, there will be no penalties of any kind to you, your school, or district. 

Your survey responses will remain confidential throughout the project. Your name and the name of your school will not be associated with your responses for the purpose of this evaluation. Taking part in this survey will cause no risk. The results of the evaluation will be used to improve support and implementation of CDC’s support to schools.

If desired, you may complete the survey over multiple sittings. After you begin, you may save, exit, reenter, and continue the survey where you left off. You can exit the survey and return as many times as needed to fully complete it.

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

Please choose one of the options below and click “next” to confirm:  

☐ I have read the above information, and I agree to participate in this survey. 

☐ I have read the above information, and I DO NOT wish to participate in this survey. If you choose this option, you will not be able to continue the survey.