2011 NH Youth Risk Behavior Survey (YRBS)

2011 NH Youth Tobacco Survey (YTS)

Parental Opt Out Form

Our school is taking part in the 2011 Youth Risk Behavior Survey and Youth Tobacco Survey sponsored by the New Hampshire Departments of Education and Health and Human Services. These research surveys will ask about the health behaviors of 9th through 12th grade students. The YRBS will ask about nutrition, physical activity, injuries, tobacco, alcohol, and other drug use. It will also ask about sexual behaviors that cause AIDS, other sexually transmitted diseases, and pregnancy. The YTS asks only about tobacco use, attitudes and perceptions of harm. Students randomly chosen by classroom will complete one or the other survey not both.

Students will be asked to fill out a questionnaire that takes about 45 minutes to complete.

Doing these paper and pencil surveys will cause little or no risk to your child. The only potential risk is that some students might find certain questions to be sensitive. The surveys have been designed to protect your child’s privacy. Students will not put their names on the surveys. Also, no class or student will ever be mentioned by name in the results. The results of this survey will help students in the future. We would like all selected students to take part in the survey, but the surveys are voluntary. No action will be taken against the school, you, or your child if your child does not participate. Students can skip any question that they do not wish to answer. In addition, students may stop participating in the survey at any point without penalty.

Please read the section below. If you do NOT want your student to take part in the survey, check the box and return the form to the school no later than 4/8/11 to Timothy Lena, Student Assistance Counselor. Please see the attached form for more facts about the surveys. If the student’s teacher or principal cannot answer your questions about either survey, please call the Department of Health and Human Services at 271-2170. Copies of the survey questionnaires are available at school if you wish to review them.

Thank you.

___________________________________________________________________________

Student’s name:___________________________________________ Grade: ______________

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

[ ] The student may NOT participate in this survey.

Parent’s signature:________________________________________ Date:_________________

Phone number: _________________________________________