Student Health Survey Opt-Out Form

Reynolds schools are participating in the Student Health Survey (SHS), a survey sponsored by the Oregon Health Authority Public Health Division and the Oregon Department of Education. The survey will gather information about health risk behaviors of students in grades 6, 8 and 11. The survey will be conducted online either in the classroom or remotely and includes questions about:

• Student health and safety
• Student mental and behavioral health
• School climate and culture

Completing the Student Health Survey poses minimal risk to your child, who may feel embarrassed or uncomfortable answering some of the questions. Survey procedures have been designed to protect your child's privacy and allow for anonymous participation. If your child is not comfortable answering a question, he or she can leave it blank. While we encourage all students to participate, the decision to participate is voluntary. You may opt to complete the form below as refusal for your child’s participation. Alternatively, your child will have the opportunity to refuse at the time of the survey. There will be no action against you or your child if your child does not participate.

Please see the following document for additional information about the SHS. If you would like to review the survey before you make a decision about your student's participation, you can view the survey on the Oregon Health Authority (OHA) Public Health website at healthoregon.org/shs.

While we encourage all students to participate, the decision to participate is voluntary. If you do not wish your child to take this survey, please complete the form below before the survey window starts on October 31, 2022. You only need to fill out this form if you do not wish your child to participate. If you have any specific questions about the survey, feel free to call your student's school.

I understand that I need to complete and sign this form if I do not want my child to take the Student Health Survey.