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Parent Form for Student to not take the survey
Posted On:
Friday, January 17, 2020

If you do not want your child to take the school survey. Click here for a copy of the Form


Dear Parent/Guardian,

Jefferson County Schools is conducting a survey about school climate and learning in school. The survey will help us create safe and supportive school environments that promote academic success. In prior years, schools have used this information to drive positive changes for student and staff culture. We are asking permission for your child to complete the survey. The survey is voluntary and anonymous. It includes questions about student relationships with teachers, school principals, and other students; school safety, bullying, and substance use; and school rules and the school environment.

This survey is sponsored by the Tennessee Department of Education. You can view the survey on the JCS website or at your child’s school. The survey will be administered to students online within the next few weeks. The survey will take about 15 minutes to complete. Students who take the survey may skip any question they do not want to answer, or may stop taking the survey at any time. Your child’s teacher will be there to help answer questions. This survey is designed to protect your child’s privacy. Students do not put their names on the survey.

Please read the section below. If you do not want your child to participate in the survey, sign the form and return it to the school within three days. You may contact your child’s teacher or principal with any questions about the survey. You may also contact Tabetha Colangione with Coordinated School Health at 865-397-3194 or

Thank you.

Child’s Name: ________________________________________________ Grade: _____________

I have read this form and understand what the survey covers. PLEASE CHECK THE BOX BELOW AND SIGN  NO, my child may not take part in this survey. ________________________________________________________________________________ Parent/Guardian Signature Date

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