File: JFJ-E (pdf)
CONSENT FOR SUBMISSION TO SURVEYS, ANALYSES, OR EVALUATIONS
In some circumstances in which a student is to be required to submit to a survey, analysis, or evaluation, the school must receive written parental consent prior to the activity.
A "survey," "analysis," or "evaluation" means a method of obtaining information, including a group activity, that is designed to elicit information about one or more of the following seven protected areas:
- political affiliations;
- mental and psychological problems potentially embarrassing to the student or his or her family;
- sex behavior and attitudes;
- illegal, anti-social, self-incriminating, and demeaning behavior;
- critical appraisals of other individuals with whom respondents have close family relationships;
- legally recognized privileged and analogous relationships, such as those of lawyers, physicians, and ministers; or
- income (other than that required by law to determine eligibility for participation in a program or for receiving financial assistance under such program).
(Complete form on next page)
On ____________________, your child will be asked to __________________________
Please complete this form and return to ______________________________ School by
____________________. Feel free to call _________________________ at __________ if
you wish to discuss this activity before signing the form.
____ I give my consent for _________________________ (student's name) to participate in a survey, analysis, or evaluation, as described above. I understand that my student may choose not to respond to any portion of, or withdraw from the activity at any time.
____ I do not give my consent for _________________________ (student's name) to participate in a survey, analysis, or evaluation, as described above. I understand that my student will be given an academic alternative in a manner that does not call particular attention to my student or my student's family.
Signature of Parent/Guardian (or of Student if an emancipated minor or 18 years of age or older)
End of File: JFJ-E