Sioux City Community School District Logo

2021 Iowa Youth Survey & Behavioral Health Survey Opt-Out Form

Dear Parent/Legally Authorized Adult:

Between September 27 and November 12, 2021, your student(s) in 6th, 8th, and/or 11th grade will
be invited to join their classmates in completing the 2021 Iowa Youth Survey. Since 1975, Iowa
students have filled out this questionnaire to provide important information about their
behaviors, experiences, and beliefs. 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 or approximately 40 minutes to complete.


Purpose of the Survey:
The 2021 Iowa Youth Survey is directed by the Iowa Department of Public Health (IDPH). Your
school system has agreed to administer the survey for 2021.


The purpose of the survey is to collect information from Iowa youth so we can better understand
their behaviors, experiences, and beliefs about what makes them feel secure, strong, and safe in
their communities, schools, and families. Students are asked about their experiences with and
perceptions of many topics, such as:
• nutrition, exercise and sleep habits;
• youth mental health;
• pandemic impacts;
• alcohol, tobacco and other drugs;
• bullying, harassment and interpersonal violence;
• extracurricular activities and volunteering; and,
• school climate and adult support.


This information helps state planning agencies, schools, and local community task forces seek
funding, set policy, and provide programs to improve the lives of Iowa’s young people. Asking
young people about their experiences and opinions is a valued part of these processes.


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 at your student's school or online at:
https://iowayouthsurvey.idph.state.ia.us/Announcements before your student(s) volunteer
to answer the questions.
3. An opportunity for you to provide written refusal if you do not want your student(s) 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
questionnaire so you can make decisions for your family.
 
Iowa Youth Survey Content:
In order to plan for the health, wellbeing and safety of all children living in Iowa, it’s important
that we understand their lives and experiences. While some sensitive questions about alcohol,
illegal drugs and violence may not apply to your student(s), these questions may be quite
relevant to others. When we know the range of experiences and values that exist in our student
population, we can better meet their needs. Your student(s) honest answers will help us reach
that goal. We value your support.

Confidentiality:
IDPH has measures in place to protect student confidentiality. All information collected will be
anonymous. Students will not put names, birthdates, or student numbers on the survey. In
publicly presented reports and reports delivered back to schools, no information about a question
will be reported for a grade level if fewer than 11 students in that grade level at that school
answer a question. IDPH may share the data collected through this survey to researchers or other
organizations for the purpose of special studies and analyses only after the receiving entity signs
an agreement with IDPH agreeing to maintain the confidentiality of all data received.

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

Voluntary:
• All students in 6th, 8th, and 11th grades will be invited to complete the Iowa Youth 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 at any time, they may do so.
• If, as a parent or legal guardian, you do not want your student(s) to participate, you must
send the school the Refusal of Consent form provided at the end of this letter (Part 3).
Your student(s) will be provided a neutral activity during the survey class period. There
is no penalty for anyone who decides not to participate.

Risk:
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.

Benefits:
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:
Questions regarding the Iowa Youth Survey are encouraged. Please contact your school
principal, superintendent, or the Iowa Department of Public Health at
iowayouthsurvey@idph.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: https://iowayouthsurvey.idph.state.ia.us/Announcements.

Part 3: Refusal of Consent
I have read the Information Summary provided. I understand that my student(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 2021 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 13, 2021. Please return this form to the building principal.

Names of child/children who will not participate in the 2021 Iowa Youth Survey and Behavioral Health Survey:

Parent Signature *
clear

NON-DISCRIMINATION STATEMENT: 

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 and does not 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.  The District is required by Title IX and 34 CFR Part 106 not to discriminate on the basis of sex in its programs, activities, or employment.   

Inquiries or grievances under Section 504  and Title II of the Americans with Disabilities Act may be directed to Dr. Dora Jung, Director of Student Services & Equity Education/Title IX Coordinator at 627 4th Street, Sioux City, IA 51101, (712) 279-6075,  jungd@live.siouxcityschools.com. Inquiries about the application of Title IX and its regulations to the District may be referred to the Title IX Coordinator, the Assistant Secretary of the U.S. Department of Education, or both. Please see District Board policies 103 and 504.4 for additional information on available grievance procedures.