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Minnesota Statutes, section 120B.31, subdivision 4a, requires the commissioner to create and publish

a form for parents and guardians to complete if they refuse to have their student participate in state-

required standardized assessments. Your student’s district may require additional information. School

districts must post this form on the district website and include it in district student handbooks.

Parent/Guardian Refusal for Student Participation in Statewide Assessments

To opt out of statewide assessments, the parent/guardian must complete this form and return it to the student’s school.

To best support school district planning, please submit this form to the student’s school no later than January 15 of the academic school year. For students who enroll after a statewide testing window begins, please submit the form within two weeks of

enrollment. A new refusal form is required each year parents/guardians wish to opt the student out of statewide assessments.

Date (This form is only applicable for the 20 to 20 school ǇĞĂƌͿ

Student’s Legal First Name Student’s Legal Middle Initial

Student’s Legal Last Name Student’s Date of Birth

Student’s District/School Grade

Please initial to indicate you have received and reviewed information about statewide testing.

I received information on statewide assessments and choose to opt my student out. MDE provides a

Parent/Guardian Guide to Statewide Testing on the MDE website (Students and Families хStatewide dĞƐƚŝŶŐͿ

Reason for refusal:

Please indicate the statewide ĂƐƐĞƐƐŵĞŶƚ;ƐͿyou are opting the student out of this school year:

MCA/MTAS Reading MCA/MTAS Science

MCA/MTAS Mathematics ACCESS or Alternate ACCESS for ELLs

Contact your school or district for the form to opt out of local assessments.

I understand that by signing this form, my student will receive a score of "not proficient" and he/she waives the opportunity to receive a college-ready score that could save time and money by not having to take remedial, noncredit courses at a Minnesota State college or university. My school and I may lose valuable information about how well my student is progressing academically. In addition, opting out may impact the school, district, and state’s efforts to equitably distribute resources and support student learning.

Parent/Guardian Name ;ƉƌŝŶƚͿ

Parent/Guardian Signature

To be completed by school or district staff only. Student ID or MARSS Number

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