Fall 2024 California Healthy Kids Survey Opt-Out

Dear 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 webform linked 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 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 - 22nd, 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

Please only complete this form if you do not give permission for your child to be in the California Healthy Kids Survey.

(If you do give permission for your child to participate, you do not need to complete this web form and your child will be included.)

1. Please enter the name and contact information of the parent or guardian completing this form:

This information is needed in case we need to contact you for clarification.
A copy of this submitted information will also be emailed to this email address. *This question is required.

First Name

Last Name

Relationship to the student

Email Address

Phone Number

3. Parent Signature:

Clear

Signature of

4. Please enter your student’s name below.
In order to help us correctly identify your student, 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 or initial
Student's last name

5. Please select your student's grade level:

Please note, only secondary students (grades 6 and up) are being invited to participate in the California Healthy Kids Survey.

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

7. 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.

8. 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.

Fall 2024 California Healthy Kids Survey Opt-Out

California Healthy Kids Survey Opt-Out Form (7th, 9th, and 11th Grade)