card header iconCalifornia Healthy Kids Survey Notification and Withdrawal Form

Dear Parent or Guardian:

Your student 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 among our youth, improve the school learning environment and combat problems such as drug abuse and violence. Please read this form for information about the survey, and for instructions on how to withdraw your child. If you do not want your child to complete the survey, you must notify your school.
Survey Content. 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.
You may examine the questionnaire in the school office or at your district’s Web site under the Parent tab.
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 (Outside Source) and type in the district name.
It is Voluntary. Your child does not have to take the survey. Students who participate only have to answer the questions they want to answer and they may stop taking it at any time.
It is Anonymous. No names will be recorded or attached to the survey forms or data. The results will be made available for analysis only under strict confidentiality controls.
Administration. The survey will be administered at each site.  It will take about one class period to complete (about 50 minutes) and will be administered in your child’s class.
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 seven 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, call Suzi Rosas at the district at 530.273.3351 ext. 217.
If you do not want your student to participate, you may contact your student’s school:
Polly Bauer  530.268.3700 ext. 4842
Tammy Shurte
530.273.4431 ext. 2007
Ghidotti -
Kathy Stephensen  530.274.5270
NU Tech -
Cindi Rogers  530.273.4431 ext. 2058
North Point -
Josephine Stewart  530.272.2643 ext 201  
Park Avenue (Silver Springs) -
Lesa St Germain  530.272.2635 ext. 321

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