2018 Iowa Youth Survey & Behavioral Health Survey Opt-Out Form

Dear Parent/Legally Authorized Adult:

Between October 1 and November 9, 2018, your child/children in 6th, 8th, and 11th grade will be invited to join their classmates in completing the 2018 Iowa Youth Survey and Behavioral Health Survey. Since 1975, Iowa students have filled out this questionnaire to provide important information about their values, beliefs, attitudes, and activities. Participation in the survey is anonymous and strictly voluntary. No student is required to fill out the questionnaire. The survey will take one class period, approximately 40 minutes, to complete.

Purpose of the Survey:

The Iowa Department of Public Health (IDPH) directs the 2018 Iowa Youth Survey. Your school system has agreed to administer the survey for 2018. The purpose of the survey is to collect information from Iowa youth so we can better understand their beliefs, values, and decisions about what makes them feel secure, strong, and safe in their communities, schools, and families. In addition, information is collected about their experiences with and ideas about alcohol, tobacco, drugs, bullying and harassment, and violence prevention. The information collected helps state planning agencies, schools, and local community task forces put together valuable future programming. It is important to ask children to tell us what is good and working about their lives in Iowa and what needs improvement.

The Behavioral Health Survey is part of the Now is the Time: Project AWARE and School Climate Transformation Grants, directed by the Iowa Department of Education. The Behavioral Health Survey asks questions about mental health, bullying, and adult student relationships. The information collected will help the district educate youth about mental health issues, including available resources.

IDPH, in consultation with the Attorney General’s Office, has developed a plan for making sure that the survey is voluntary and has parent approval. This plan is called a “passive consent” procedure and has three parts:

  1. An Information Summary to give you basic information about the survey (below).
  2. An opportunity for you to read the survey questions.
  1. An opportunity for you to provide written refusal if you do not want your child/children to participate in the survey.

Part 1. The Information Summary

Parental Rights:

  • You have the right and the responsibility to be informed about what your child volunteers to participate in at school.
  • You have the right to receive accurate information about the Iowa Youth Survey and Behavioral Health Survey questionnaires so you can make decisions for your family.

Iowa Youth Survey Content:

Some areas on the questionnaire will have sensitive questions about tobacco, alcohol, illegal drugs, and thoughts on violence and safety. It is important to remember that our school children do not live in identical environments. All children and families do not have the same beliefs, attitudes or values. Your child/children may make very different life choices than other children. If we are going to plan programming that keeps all children safe and connected to their families, schools and communities, we need to know what all Iowa children are thinking, saying and doing.

Behavioral Health Survey Content:

The Behavioral Health Survey asks questions about mental health, bullying, and adult student relationships. The information collected will help the district educate youth about mental health issues, including available resources.


All information collected will be anonymous. Students will not put names, birthdates, or student numbers on the survey, and all surveys will be confidential. IDPH also has additional restrictions in place to further protect student confidentiality. For example, if fewer than 11 students in a grade level at a school answer a question, no information about that question will be reported for that grade level. Grade level information will be added together and reported as a school system. The information will then be analyzed by the Iowa Consortium for Substance Abuse Research and Evaluation and McREL International will have access to the raw survey data, and will analyze and report on the data in school- and district-level reports.


There will be no compensation or reward for students participating in the survey.


  • All students in 6th, 8th, and 11th grades will be invited to complete the Iowa Youth Survey and Behavioral Health Survey. Students will have the right to refuse to participate in the survey and to refuse to answer any questions on the survey. If students decide they want to change their mind and quit answering the survey during the survey, they may do so.
  • If, as a parent or legally authorized representative, you do not want your child/children to participate, you must send the school the Refusal of Consent form provided at the end of this letter (Part 3), and your child/children will be provided a neutral activity during the survey class period. There is no penalty for anyone who decides not to participate.


There is no direct risk involved in filling out the survey. Students may find some questions uncomfortable to answer. They may skip any question they do not wish to answer or stop completing the survey entirely at any point.


There will be no direct benefits to the students the day of the survey. The data collected throughout the state will provide schools and communities with the information they need to provide programs that will support schools, communities and families in keeping their children safe and hopeful about their future. The data are vital for grant writing purposes and legislative decisions.


Questions regarding these surveys are encouraged.

  • For questions regarding the Iowa Youth Survey, please contact your school principal, superintendent, or the Iowa Department of Public Health at iowayouthsurvey@idph.iowa.gov.
  • For questions regarding the Behavioral Health Survey, please contact your school grant manager, school principal, superintendent, or Molly Hammer at the Iowa Department of Education at molly.hammer@iowa.gov.

Part 2. Reviewing the Survey

A copy of the Iowa Youth Survey will be available to preview at the school office and may also be viewed at http://www.iowayouthsurvey.iowa.gov/2018_announcements.html. A copy of the Behavioral Health Survey will be available to preview at the school office.

Part 3. Refusal of Consent

I have read the Information Summary provided. I understand that my child/children’s participation in the survey is strictly voluntary. I also understand my right to review the survey online, at the school office and/or District Administration Office.

My signature below states: I do not want my child/children listed below to participate in the 2018 Iowa Youth Survey and Behavioral Health Survey. I understand that a neutral activity will be provided for them during the survey time and that there is no penalty for not participating. I understand that this refusal of consent needs to be received by the school system no later than September 14, 2018. Please return this form to the building principal.

Names of child/children who will not participate in the 2018 Iowa Youth Survey and Behavioral Health Survey:

Parent Signature *


The Sioux City Community School District offers career and technical programs in the following areas: Business & Marketing, Family & Consumer Science, Health Science, and Industrial Arts, Technology, & PLTW.

The Sioux City Community School District is an equal opportunity/affirmative action employer. It is an unfair or discriminatory practice for any educational institution to discriminate on the basis of race, creed, color, sex, sexual orientation, gender identity, genetic information (for employment), national origin, religion, age (for employment), disability, socioeconomic status (for programs), marital status (for programs), or veteran status (for employment) in its educational programs and its employment practices.

Inquiries or grievances, including Section 504 grievances and grievances under Title II of the Americans with Disabilities Act, may be directed to Jen Gomez, Director of Student Services & Equity Education at 627 4th Street, Sioux City, IA 51101, (712) 279-6075, gomezj2@live.siouxcityschools.com. Please see District Board policies 103 and 504.4 for additional information on available grievance procedures.