Parental Consent Form

Appendix A Active Consent Form Approved

OMB No: 1850-0818

Expiration Date: XX/XX/XX

Parental Consent Form: Health Behaviors and School Experiences Survey

Dear Parent or Guardian:

Your child’s school will be taking part in an important national study to evaluate the effect of school policies and procedures on student attitudes and experiences. This study is funded by the Office of Safe and Drug Free Schools and is being conducted by RMC Research Corporation under a contract with the U.S. Department of Education. Your child has been randomly selected to complete a survey as part of this study.

We would very much like for your child to participate in this survey. Your child’s participation will help increase the Department of Education’s understanding of these important topics. If you allow your child to participate, he or she may be asked to complete a survey once or twice a year while in high school (up to a total of five times). The survey asks about several topics, including attitudes toward and use of alcohol and other drugs, participation in extracurricular activities, and school pride and connectedness. Your child will be provided a list of resources they can contact if they wish to talk to someone about questions or feelings they may have about the survey.

The survey will be completed in a group setting during school hours at your child’s school, and should take no longer than 30 minutes to complete. If you wish, you may review a blank copy of the survey at the school. The collection of information in this study is authorized by Public Law 107-279 Education Sciences Reform Act of 2002, Title I, Part C, Sec. 151(b) and Sec. 153(a). Participation is voluntary. Your child will receive a gift card to see a movie at [NAME OF THEATER] as a thank-you for your return of this consent form. Your child’s responses are protected from disclosure by federal statute (PL 107-279 Title I, Part C, Sec. 183). All responses that relate to or describe identifiable characteristics of individuals may be used only for statistical purposes and may not be disclosed, or used, in identifiable form for any other purpose, unless otherwise compelled by law. Data will be combined to produce statistical reports. No individual data that links your name, address, telephone number, or identification number with your responses will be included in the statistical reports.

Participation in this study is completely voluntary. Even if you give your consent now, your child may withdraw from the study later, without penalty. Your child's grades, standing in school, and eligibility to participate in school sports or other school activities will not change, whether or not he or she participates in this survey.

We have enclosed a permission form for you to complete. We suggest that you talk to your child about your decision to allow him or her the opportunity to participate in the study. Please complete the form and return it in the enclosed envelope within one week.

If you have any questions about the study or your child’s participation, please contact Eric Einspruch, the study’s Project Director, at RMC Research, 1-800-788-1887. If you have any concerns or questions regarding your child’s rights as a study participant, you may contact the Human Subjects Research Review Committee in the Office of Research and Sponsored Projects, 111 Cramer Hall, Portland State University, 1-877-480-4400. Thank you in advance for your help with this important study.

Sincerely,

Eric Einspruch

Project Director

Parental Consent Form

Health Behavior and School Experiences Survey

Please check the box indicating whether or not you consent for your child to participate in the study. Please sign both copies of this form. Return one copy to RMC Research Corporation in the enclosed, return-addressed envelope and keep one for yourself.

Child’s First Name: ______________________________________

Child’s Last Name: ______________________________________

Child’s Date of Birth: | | | / | | | / | | | | | (Month/Day/Year)

Child’s Gender:  Male  Female

 YES, I give permission for my child to participate in this survey.

 NO, I do not give permission for my child to participate in this survey. Child’s First Name Last Name

Please sign below. Your permission is only valid if you sign.

X

Parent/Guardian signature on this line		Date
Print the name of the parent or guardian on this line.
Parent or Guardian Home Telephone Number: (| | | |)-| | | |-| | | | | Parent or Guardian Work Telephone Number: (| | | |)-| | | |-| | | | | Parent or Guardian Alternative Telephone Number: (| | | |)-| | | |-| | | | |

1