Farragut Elementary School

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California Healthy Kids Survey » California Healthy Kids Survey - Consent Form

California Healthy Kids Survey - Consent Form

Consent for the California Healthy Kids Survey

2017-18 School Year


Dear Parent or Guardian:

Your child is being asked to be a part of our school’s California Healthy Kids Survey (CHKS), sponsored by the California Department of Education. This is a very important survey that will help promote better health and well-being among our youth, improve the school learning environment, and combat problems such as drug abuse and violence. Your child does not have to take the survey. Participation is voluntary and requires your permission.

Survey Content. The survey gathers information on developmental supports provided to youth; school connectedness and barriers to learning, as well as behaviors such as physical activity and nutritional habits; alcohol, tobacco and other drug use; and school safety.

You may examine the questionnaire at the following link: http://chks.wested.org/wp-content/uploads/chks-elem-bilingual-1718_watermark.pdf

The results from this survey are compiled into district and county-level CHKS Reports. To view a copy of your district’s report, go to http://chks.wested.org/reports/search (Outside Source) and type in the district name.

It is Voluntary. Students who, with your permission, agree to participate do not have to answer any questions they do not want to answer, and may stop taking the survey at any time.

It is Anonymous. No names are recorded or attached to the survey forms or data. The results will be made available for analysis only under strict confidentiality controls.

Administration. The survey will be administered in November 2017. It will take about one class period to complete (about 50 minutes) and will be administered in your child’s regular fifth grade class.

Potential Risks. There are no known risks of physical harm to your child. Risks of psychological or social harm are very small. None have been reported in seven years of survey administration. In rare instances, some discomfort might be experienced from the questions. The school’s counseling services will be available to answer any personal questions that may materialize.

For Further Information. The survey was developed by WestEd, a public, non-profit educational institution. If you have any questions about this survey, or about your rights, please contact Rebecca Ngo, (310) 842-4323


Parent Consent Form for the California Healthy Kids Survey

Please check below whether you grant permission, sign, and return this form within three days to the teacher who distributed it.

___ I give permission for my child to be in the California Healthy Kids Survey.

___ I do not give permission for my child to be in the California Healthy Kids Survey.

Signature: Date:

My child’s name is:

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