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INFORMED CONSENT FORM [printable version in pdf ] MICHIGAN ALCOHOL AND OTHER DRUG SCHOOL SURVEY Our School District, in collaboration with Western Michigan University and the Michigan Department of Education, is conducting a survey among the eighth, tenth and twelfth graders of the School District to determine the extent of students' contact with and use of tobacco, alcohol, and other drugs. We are asking that the students be permitted to fill out a short survey form providing this information. This survey is being undertaken in this School District and many other School Districts in the State of Michigan in order to determine if there is a problem, the extent of the problem, and to be eligible for funding for programs on alcohol and drug education, should we want them. We request your cooperation, but will not identify or penalize any student who does not participate in this survey. The students will not sign the survey or in any other way be identified. The participation of students is completely voluntary. Students will not participate if they do not want to, or if their parents or guardians do not wish them to participate. If for any reason you do not wish your son or daughter to participate in the survey, please sign this form and either return it by mail or have your son or daughter return it to his/her teacher. For more information contact:
Parent's Signature __________________________________________
Student's Name __________________________________________ |
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