California Healthy Kids Survey
Active Consent form for Elementary School
Sign in to Google to save your progress. Learn more
Your child is being asked to be a part of our school’s California Healthy Kids Survey (CHKS) sponsored by the California Department of Education. This is a very important survey that will help promote better health and well-being among our youth, improve the school learning environment and combat problems such as drug abuse and violence. Your child does not have to take the survey. If you do not want your child to complete the survey, you must notify your school.
The survey gathers information on developmental supports provided to youth; school connectedness and barriers to learning; school safety; and health-related concerns such as physical activity and nutritional habits; alcohol, tobacco and other drug use; and risk of depression and suicide and perceived sexual orientation.

The results from this survey are compiled into district- and county-level CHKS Reports. To view a copy of your district’s report, go to https://calschls.org/reports-data/search-lea-reports/ and type in the district name.  It is Voluntary. Students who, with your 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. The results will be made available for analysis only under strict confidentiality controls.

The survey will be administered on January 25 – February 5.  It will take about one class period to complete (about 40 minutes).

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 20 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 Gloria Daniels Valdez, Gloria_daniels@jusd.k12.ca.us 
Parent Consent
Clear selection
School Site *
Enter Your Child's Name and Grade *
Enter Your Name and Date *
Submit
Clear form
Never submit passwords through Google Forms.
This form was created inside of Jurupa Unified School District. Report Abuse