Student School Climate Survey Parental Passive Consent Form printable pdf download

PASSIVE

CONSENT

TUDENT

CHOOL

LIMATE

URVEY

ARENTAL

ORM

As part of the WV Safe and Supportive Schools Initiative, schools in your county are taking part in the

WV School Climate Student Survey. This survey is being sponsored by the West Virginia Department of

Education, Office of Healthy Schools. Students taking the survey will be asked about health behaviors,

including tobacco, alcohol, and other drug use, as well as their opinions about school safety.

The survey will be administered online in a school‐based computer laboratory on a date selected by the

principal of your child’s school. The survey will take about 20 to 30 minutes for the students to

complete.

Completing the online survey will cause little or no risk to your child. The only potential risk is that some

students might find the topic of some survey questions to be sensitive. The survey has been designed to

protect your child’s privacy. Students will not be asked to put their names on the survey. No student

will ever be mentioned by name in a report of the results. Some schools may not have enough

computer labs for all students to participate. As such, your child may not be selected to participate.

The results of this survey will be used to make changes in schools to ensure a positive climate for

learning. While your child may get no benefit right away from taking part in the survey, the changes

made at the school may help your child and other children in the future. We would like all selected

students to take part in the survey, but the survey is voluntary. No action will be taken against the

school, you, or your child if your child does not take part. Students may skip any questions they do not

wish to answer. In addition, students may stop participating in the survey at any point without penalty.

You may contact your child’s school if you have questions. You also may request to see a copy of the

survey at the school office.

Please read the section below and check the box only if you do not want your child to take part in the

survey. If you check the box “no” below, sign this form and return it to your child’s school.

Thank you.

Student’s name

:___________________________________________ Grade: _____

(Please Print)

I have read this form and know what the survey is about.



NO, I do not give permission, my child MAY NOT take part in the WV School Climate Student

Survey .

Parent’s signature: __________________________________________ Date: ___/___/______

Phone number: __________________________________________

Student School Climate Survey Parental Passive Consent Form