Weight Status Nonparticipation Form for 23-24 Survey

As part of a required school health examination, a student is weighed, and his/her height is measured. These numbers are used to figure out the student’s body mass index or ‘BMI’.  The BMI helps the doctor or nurse know if the student’s weight is in a healthy range or is too high or too low.  Recent changes to the New York State Education Law require that BMI and weight status group be included as part of the student’s school health examination.  A sample of school districts will be selected to take part in a survey by the New York State Department of Health.  If our school is selected to be part of the survey, we will be reporting to New York State Department of Health information about our students’ weight status groups.  Only summary information is sent.  No names and no information about individual students are sent.  However, you may choose to have your child’s information excluded from this survey report.

The information sent to the New York State Department of Health will help health officials develop programs that make it easier for children to be healthier.

If you do not wish to have your child’s weight status group information included as part of the Health Department’s survey this year, please print and sign your name below and return this form before January 3, 2023 to: 

Elementary Nurse’s Office - 607 698 4225 Ext. 1116

High School Nurse’s Office - 607 698 4225 Ext 2407

Please do not include my child’s weight status information in the 2023-2024 School Survey.


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Print Child’s Name                                                                  Date


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Print Parent’s Name                                                              Parent’s Signature