Second Step Survey Permission Form
Our school is working together with the Kansas Department of Health and Environment (KDHE) to apply the Committee for Children’s Second Step Social Emotional Learning program.  The program teaches self-management skills, healthy relationship skills, and goal setting skills. It looks at bullying, relationships\dating, sexual harassment, and bystander behavior.  Part of applying the program is asking students to participate in a pre- and post-survey to help us measure the success of carrying out the program.  The pre- and post-survey includes questions related to knowledge, attitudes and behavior that lead to or support bullying, sexual harassment, and bystander behavior and those that lead to a safe school climate.

The survey has been designed to protect your child’s privacy.  Students will not put their names on the pre and post-test survey.  However, if the survey flags that a child needs additional assistance, the school will be given notice to give that child help using their student ID. The combined summary results of the tests will not mention the name of any student participating in the pre and post-survey.  The results will help your child’s school discover if there are any areas of bullying or school safety that need more attention in the school. The test results will not only help your school find out how to make it a safer place, but it can also help other children in the future.  However, the participation in the pre- and post-survey to determine the success of the Second Step Program is voluntary. No action will be taken against the school, you, or your child, if your child does not participate in the pre- and post-survey.

Please read the section below. If you want your child to take part in the pre- and post-survey, check the box and return the form to the school no later than December 6, 2019. If your child’s teacher or principal cannot answer your questions about the Second Step Program, please call Stefanie Olson at Kansas Department of Health and Environment at 785-296-8476.  Thank you.

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Email *
I have read this form and know what the pre- and post-survey is about. *
My child may take part in the pre- and post-survey. *
Student Name *
Student School *
Student Grade *
Parent Name *
Parent Phone Number *
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