South Central Calhoun CSD 

Prior Written Consent 

Under SF 496 districts are required to provide parents with prior witten consent forms before administering the following:

• • • A formal examination or survey designed to assess a student’s mental, emotional, or physical health not required by federal or state law. 

    • Any survey, analysis, activity, or evaluation that may reveal information on the student or the student’s family, including political affiliations and beliefs; mental or physiological problems; sexual behavior, orientation, or attitudes; illegal, antisocial, self-incriminating, or demeaning behavior; critical appraisals of others with whom the child has familial relations; legally recognized privileged or analogous relationships, religious practices, affiliations, and beliefs; and income, except as provided by law.  

  • 1. The board of directors of a school district must receive the prior written consent of a student's parent or guardian before requiring a student to take part in any survey, analysis, activity, or evaluation that reveals information concerning any of the following about the student or the student's family, whether the information is personally identifiable or not:

a. The political affiliations or beliefs of the student or the student's parent or guardian.

b. Mental or psychological problems of the student or the student's family.

c. Sexual behavior, orientation, or attitudes.

d. Illegal, antisocial, self-incriminating, or demeaning behavior.

e. Critical appraisals of other individuals with whom the student has close familial relationships.

f. Legally recognized privileged or analogous relationships, such as those of attorneys, physicians, or ministers.

g. Religious practices, affiliations, or beliefs of the student or the student's parent or guardian.

h. Income, except when required by law to determine eligibility for participation in a program or for receiving assistance under such a program.

• • 2. An employee of a school district, or a contractor engaged by a school district, shall not answer any question pertaining to any particular student enrolled in the school district in any survey related to the social or emotional abilities, competencies, or characteristics of the student, unless the board of directors of the school district satisfies all of the following requirements:

a. The board of directors of the school district provides to the parent or guardian of each student enrolled in the school district detailed information related to the survey, including the person who created the survey, the person who sponsors the survey, how information generated by the survey is used, and how information generated by the survey is stored.

b. The board of directors of the school district receives the written consent from a student's parent or     guardian authorizing the employee or contractor to answer questions in the survey pertaining to the student.

• • 3. Subsection 2 shall not be construed to prohibit an employee of a school district, or a contractor engaged by a school district, from answering questions pertaining to any particular student enrolled in the school district as part of the process of developing or implementing an individualized education program for such student.

Iowa Code § 279.79

Below is a link to the general form that will be used to gain permission (if any of the prior situations exist in the district). Please note that this form is subject to change with any given survey as it will likely be tailored to add additional information regarding each individual survey and the purpose/s for providing it in the school setting. 

(Sample) General  Permissions Form