California Common Core Data Opt-Out Form

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California Common Core Data Opt-Out Form
Please take notice that pursuant to California Education Code §§ 51513, 60614, 60615 and 20 U.S.C. §
1232(h), my child is to be exempted and excused from the following activities:
Taking any and all statewide performance assessments, including but not by way of limitation to,
1)
academic, achievement and annual tests, and Common Core interim and formative assessments,
administered pursuant to sections 60600, et seq. (Calif. Educ. § 60615);
2) The administration of any test, questionnaire, survey, examination or evaluation containing any
questions or items relative to my child, or my personal beliefs or practices in sex, family life,
morality, or religion (Calif. Educ. § 51513);
3) The administration of any test, examination, or assessment as part of a statewide pupil assessment
program relative to my child, or my personal beliefs or practices in sex, family life, morality, or
religion, or any question designed to evaluate personal behavioral characteristics, including, but not
limited to, honesty, integrity, sociability, or self-esteem (Calif. Educ. § 60614);
4) The administration of any survey, analysis or evaluation that reveals: (1) political affiliations or
beliefs of my child or me, (2) mental or psychological problems of my child or his or her family, (3)
sexual behavior or attitudes, (4) illegal, anti-social, self-incriminating, or demeaning behavior, (5)
critical appraisals of other individuals with whom respondents have close family relationships, (6)
legally recognized privileged or analogous relationships, such as those of lawyers, physicians, and
ministers, (7) religious practices, affiliations, or beliefs of my child or me, or (8) income (other than
that required by law to determine eligibility for participation in a program or for receiving financial
assistance under such program.) (20 U.S.C. § 1232(h))
Keep this signed, written notice on file in my child’s cumulative folder. This form supersedes all prior
Opt-Out forms.
Child’s Name __________________________ Grade Level _________ Date__________________
Parent/Guardian’s Name(s)
__________________________ ___________________________
Parent/Guardian’s Signature(s) _________________________ ____________________________
Parent/Guardians(s) Address ________________________________________________________
Daytime/Evening Phone Number(s) ________________________ _________________________
School Name __________________________ School District _____________________________
Received by (Name) ______________________________________________________________
Signature _________________________________ Date Received _________________________
Version 131105_1450

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