Fall 2024 California Healthy Kids Consent Form- 6th Grade Opt-In

California Healthy Kids Survey 6th Grade Consent Form (6th Grade)

Dear 6th Grade Parent or Guardian:

Your child is being asked to participate our school’s California Healthy Kids Survey (CHKS), sponsored by the California Department of Education. The purpose of this important and informative survey is to help promote better health and well-being among students, improve the school culture and learning environment, and combat problems such as drug abuse and violence. This survey is completely voluntary- your child does not have to take the survey.

If you want your child to complete the survey, you must complete the consent form below.

Survey Content. The survey gathers information on a variety of developmental supports provided to students including: school connectedness and barriers to learning; school safety; health-related concerns such as physical activity and nutritional habits; alcohol, tobacco and other drug use; risk of depression and suicide; and perceived sexual orientation.

The results from this survey are compiled into district- and county-level CHKS Reports. Pasadena Unified School District then uses this data to provided support and additional resources to the schools, staff, and students.

It is Voluntary. Students who, with parental 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 whatsoever.

Administration. The survey will be administered between November 4th - 22th, 2024. It will take about 20 minutes to complete.

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 22 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, contact at (626)396-3600 x88239 or reynoso.julianne@pusd.us

1. Do you grant permission for your 6th student to participate in the California Healthy Kids Survey? *This question is required.

2. Parent Signature:

Clear

Signature of

3. Please enter your student’s name below.
Please enter your student’s full name as it appears on the student’s birth certificate/adoption papers.
*This question is required.

Student's first name
Student's middle name/initial
Student's last name

4. Please note, this form is only needed for 6th grade students.
Only secondary students (grades 6 and up) will participate in the California Healthy Kids Survey

Which school does your student attend? *This question is required.

5. Please enter your student’s District Student ID number (also called lunch ID):
This is the most accurate way to identify your student’s record in our student information system. This question requires a valid number format.

6. Please enter the email address where we can email a copy of this completed request for your record: This question requires a valid email address.