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Sample PPRA Notice and Consent/Opt‑Out Forms
for Specific Activities The
Protection of Pupil Rights Amendment (PPRA), 20 U.S.C. § 1232h, requires the Rochester
School Department to notify you and obtain consent or allow you to opt your
child out of participating in certain school activities. These activities
include a student survey, analysis, or evaluation that concerns one or more
of the following eight areas ("protected information surveys"): 1.
Political affiliations or beliefs of the student or student's parent; 2.
Mental or psychological problems of the student or student's family; 3.
Sex behavior or attitudes; 4.
Illegal, anti‑social, self‑incriminating, or demeaning
behavior; 5.
Critical appraisals of others with whom respondents have close family
relationships; 6. Legally recognized privileged
relationships, such as with lawyers, doctors, or ministers; 7. Religious practices, affiliations,
or beliefs of the student or parents; or 8.
Income, other than as required by law to determine program eligibility. This requirement
also applies to the collection, disclosure or use of student information for
marketing purposes ("marketing surveys"), and certain physical
exams and screenings. Following
is a schedule of activities requiring parental notice and consent or opt‑out
for the upcoming school year. (Please note that this notice and consent/opt‑out
transfers from parents to any student who is 18 or older or an emancipated
minor under State law.) |
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SAMPLE Date: On or about Grades: Five and Six Activity: Summary: This is an anonymous survey that asks
students questions about behaviors such as drug and alcohol use, sexual
conduct, violence, and other at‑risk behaviors. The survey also asks questions
of a demographic nature concerning family make‑up, the relationship
between parents and children, and use of alcohol and drugs at home. Consent
[for U.S. Department of Education funded, protected information surveys
only]: A parent must sign and return the attached consent form no later than
[insert return date] so that your child may participate in this survey. Opt‑out
[for any protected information survey not funded by the U.S. Department of
Education]: Contact [school official] at [telephone number, email, address,
etc.] no later than [date] if you do not want your child to participate in
this activity. SAMPLE Date: November 22 ‑ 24, 2002 Grades: One through Six Activity: Flu Shots Summary: The County Department of Public Health
Services will administer flu shots for influenza types A and B. Opt‑out:
Contact [school official] at [telephone number, email, address, etc.] no
later than [date] if you do not want your child to participate in this
activity. It is
contrary to the policies of the Rochester School Department to release
personally identifiable information about students to commercial services
without specific prior permission to do so.
Rather than release the protected information, parents or eligible
students will normally be notified by the School Department of the
availability of any services deemed to be sufficiently beneficial to the
students or their families to warrant such notice (e.g. low cost student
accident insurance, commercial driver education programs, etc.) and will be
given sufficient information to permit them to contact the providers
directly. Consent: A
parent must sign and return the attached consent form no later than [insert
return date] so that your child may participate in this activity. If you wish
to review any survey instrument or instructional material used in connection
with any protected information or marketing survey, please submit a request
to [school official, address]. [School official] will notify you of the time
and place where you may review these materials. You have the right to review
a survey and/or instructional materials before the survey is administered to
a student. " " " " " " "
" " " " " " " " " " I [parent's name]give my consent for [child's name] to take the Parent's
signature Please
return this form no later than [insert date] to the following school
official: [Provide name and mailing address.] Adopted: |