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English
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School District
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Academy District 20
Fountain-Fort Carson School District 8
Harrison School District 2
Lewis Palmer School District 38
Poudre School District
St. Vrain School District
Thompson School District
Weld School District (including RE-1, RE-2, RE-4, RE-5J, Greeley 6, Weld 8)
Other (Including Private Schools)
Academy District 20
Fountain-Fort Carson School District 8
Harrison School District 2
Lewis Palmer School District 38
Poudre School District
St. Vrain School District
Thompson School District
Weld School District (including RE-1, RE-2, RE-4, RE-5J, Greeley 6, Weld 8)
Other (Including Private Schools)
School
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Academy Endeavor Elementary Academy International Elementary Air Academy High School Antelope Trails Elementary Aspen Valley High School Aspen Valley Middle School Challenger Middle School Chinook Trail Elementary Discovery Canyon Campus Elementary Discovery Canyon Campus Middle School Discovery Canyon Campus High School Discovery Trail Elementary Douglass Valley Elementary Eagleview Middle School Edith Wolford Elementary Explorer Elementary Foothils Elementary Frontier Elementary High Plains Elementary Journey Elementary Journey Middle School Legacy Peak Elementary Liberty High School Mountain Ridge Middle School Mountain View Elementary Pine Creek High School Pioneer Elementary Prairie Hills Elementary Ranch Creek Elementary Rampart High School Rockrimmon Elementary The da Vinci Academy Timberview Middle School Woodmen- Roberts Elementary Other
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Abrams Elementary Aragon Elementary Carson Middle School Eagleside Elementary Fountain Middle School Fountain-Fort Carson High School Jordahl Elementary Mesa Elementary Mountainside Elementary Patriot Elementary Weikel Elementary Other
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Atlas Preparatory Elementary Atlas Preparatory Middle School Atlas Preparatory High School Bricker Elementary Carmel Community School Centennial Elementary Fox Meadow Middle School Giberson Elementary Harrison High School James Irwin Elementary James Irwin Middle School James Irwin High School Monterey Elementary Mountain Vista Community School Oak Creek Elementary Otero Elementary Panorama Middle School Pikes Peak Elementary Sand Creek International School Sierra High School Soaring Eagles Elementary Stratmoor Hills Elementary Stratton Meadows Elementary The Vanguard School Elementary The Vanguard School Secondary Turman Elementary Wildflower Elementary Other Harrison
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Lewis Palmer High School
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Bacon Bamford Bauder Beattie Bennett Bethke Blevins Boltz Cache La Poudre Elementary Cache La Poudre Middle Centennial High School Dunn Eyestone Fort Collins High School Fossil Ridge High School Harris Bilingual Irish Johnson Kinard Kruse Laurel Lesher Liberty Common Elementary School Liberty Common Middle School Liberty Common High School Lincoln Middle School Linton Livermore Lopez McGraw O'Dea Olander Polaris ES Polaris HS Polaris MS Poudre Community Academy High School (PCA) Poudre High School Preston Putnam Red Feather Lakes Rice Riffenburgh Rocky Mountain High School Shepardson Stove Prairie Tavelli Timnath Elementary School Timnath High School Timnath Middle School Traut Webber Wellington High School Wellington Middle School Werner Zach Other
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Berthoud Elementary Berthoud High School BF Kitchen Big Thompson Bill Reed Carrie Martin Centennial Conrad Ball Cottonwood Plains Coyote Ridge Ferguson High School Garfield High Plains Elementary School High Plains Middle School Ivy Stockwell Laurene Edmonson Lincoln Loveland Classical School Loveland High School Lucile Erwin Mary Blair Monroe Mountain View High School Namaqua New Vision Elementary School New Vision Middle School Ponderosa Riverview Elementary Riverview Middle School Sarah Milner Stansberry Thompson Valley High School Truscott Turner Van Buren Walt Clark Winona Other
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Estes Park Elementary Estes Park Middle School Estes Park High School Heritage Christian Resurrection Christian ES Resurrection Christian MS Resurrection Christian HS St. Joseph's Academy of Arts and Knowledge (TR Paul) Other
Fill out the permission form below for your student to participate in the free cholesterol screening.
Student's First Name
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Student's Last Name
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Student's Date of Birth
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M-D-Y
Student's Sex Assigned at Birth
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Male
Female
Sex assigned at birth is needed to calculate screening results.
Click here if your student identifies with a sex different than the one assigned at birth.
Click here if your student identifies with a sex different than the one assigned at birth.
Student ID (known as lunch #)
Used as a unique identifier only. This information will be kept confidential.
For middle and high school students only. If unsure please ask your child!
All results are entered in EPIC (electronic medical record used by UCHealth, Assoc. in Family Medicine, etc.). Your health care provider will receive your student's results in EPIC and you can view them in MyHealthConnection.
Click here if your health care provider does not use EPIC (Banner, Kaiser, Youth Clinic, etc.) or you are unsure and you'd like them to receive a copy of your student's results.
Click here if your health care provider does not use EPIC (Banner, Kaiser, Youth Clinic, etc.) or you are unsure and you'd like them to receive a copy of your student's results.
Healthcare Provider's Name
ex. Dr. Brown
Healthcare Provider's Clinic or Address
I would like my student to take part in the Healthy Hearts and Minds Screening.
I permit my student to take part in the Healthy Hearts and Minds screening and health surveys. I understand a blood sample will be obtained by finger stick method. I understand that weight/height (BMI) and blood pressure measurements will be obtained. I agree to release UCHealth, the participating school districts and their employees, officers, directors, successors, and assigns from any liability in any way connected with this screening and its measurements. Please note: The results of your student's Healthy Hearts and Minds screening provide you with information about your student's current health and possible future risk for heart disease. Abnormal results, in most cases, DO NOT indicate an emergency. Contact your student's healthcare provider for guidance. Parent/Guardian First Name
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Parent/Guardian Last Name
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Mother
Father
Other
Describe Relationship with Student
If you do not provide an email, you will not receive a notification when your student's results are viewable.NOTE: You will receive an email after your child has been screened with instructions on how to access the results via MyHealthConnection.
In signing this consent, I understand the following:
That all participation is voluntary and can be withdrawn at any time. That all information provided will be handled confidentially and stored in a secure and private location. That involvement poses minimal risk to participants. That the results will be used to educate my student about living a healthy heart lifestyle and for assessment and awareness purposes. That all data is collected and used by Healthy Hearts and Minds for research purposes and to study trends. No individual data will appear in data reports; only aggregate, de-identified, summary data will be reported in order to protect the privacy of the participants. That in collaboration with your school district, and in an effort to study community health trends and further research, Healthy Hearts and Minds and your school district may request de-identified student information using the provided student ID. No individual identifying health or academic information will be shared between UCHealth and the school district. That I can contact Healthy Hearts and Minds at 970-624-5298 to ask any additional questions. In signing this consent, I understand the following:
That all participation is voluntary and can be withdrawn at any time. That all information provided will be handled confidentially and stored in a secure and private location. That involvement poses minimal risk to participants. That the results will be used to educate my student about living a healthy heart lifestyle and for assessment and awareness purposes. That all data is collected and used by Healthy Hearts and Minds for research purposes and to study trends. No individual data will appear in data reports; only aggregate, de-identified, summary data will be reported in order to protect the privacy of the participants. That I can contact Healthy Hearts and Minds at 970-624-5298 to ask any additional questions. Based on my student's results, Healthy Hearts and Minds can contact me for follow-up on abnormal values, to inform me about potential family programs, and/or research opportunities.
* must provide value
Yes
No
By signing below I verify: I have discussed this screening with my student and am giving my permission for them to participate. Students may decide not to participate in the screening even if parents have given full permission.
Parent/Guardian Signature
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Click Add signature button and sign with mouse or finger. Make sure to hit save!
Family Health Questionnaire Click the Submit button at the bottom of this form to complete the permission for your student. Part 1: Health Habits
2. How many days per week do YOU (parent/guardian) eat breakfast?
3. How many servings per day do YOU (parent/guardian) eat of fruits and vegetables combined, not including juice? (1 serving is 1 cup of raw or 1/2 cup cooked)
1. Does anyone in the student's immediate biological family (mother, father, brother, sister) have:
Yes
No
Do not know
Yes
No
Do not know
Yes
No
Do not know
Yes
No
Do not know
e. Depression, anxiety, or mental illness?
Yes
No
Do not know
Yes
No
Do not know
Yes
No
Do not know
h. Heart Disease or Heart Attack (before age 55 in men or 65 in women)?
Yes
No
Do not know
2. Does your student have asthma?
Yes
No
Do not know
3. Does your student have diabetes?
Yes
No
Do not know
1. How many days per week do YOU (parent/guardian) get at least 30 minutes of exercise?
2. Does anyone in the family smoke?
Yes No
3. Does anyone in the family use electronic cigarettes/vape pens such as Juuls, Suorin drop, etc.?
Yes No
If yes, do you smoke or vape in the home or in the car?
Yes No
4. How many hours of sleep do YOU (parent/guardian) average per night?
5. How would you describe your stress/anxiety level over the past few weeks?
No stress
Low stress
Average stress
High stress
Very high stress
No stress
Low stress
Average stress
High stress
Very high stress
Part 4: Demographic Information
1. What is the race/ethnicity of your student?Check all that apply
White
Hispanic or Latino
Black
Asian or Pacific Islander
Other
White
Hispanic or Latino
Black
Asian or Pacific Islander
Other
Please describe student's race/ethnicity.
2. What is your (parent/guardian) age bracket?
< 25 years
25-30 years
31-40 years
41-50 years
51-60 years
>60 years
< 25 years
25-30 years
31-40 years
41-50 years
51-60 years
>60 years
3. Does your family participate in the free and reduced lunch program at your school?
Yes
No
4. What is your (parent/guardian) highest education level?
Some high school
High school degree
Some college
Technical or trade school
College degree
Some post grad work
Post grad degree
Some high school
High school degree
Some college
Technical or trade school
College degree
Some post grad work
Post grad degree
5. What is your (parent/guardian) marital status?
Married
Divorced
Single
Other
Prefer not to say
Married
Divorced
Single
Other
Prefer not to say
Reminder: You will receive a confirmation email and a notification email indicating your student's screening has been completed. Please verify your email address before clicking Submit. ______ If incorrect, please scroll up to make any changes you need in the parent/guardian email field. ______ ______ .
