PDE 4092:

2011-2012 blank printable form

Instructions for filling out the PDE 4092

Safe Schools Online

Sample Parent and Screening Consent Forms

In June 2011, a new question was added to the SAP Frequently Asked Questions and Best Practice Responses. To assist with implementation and clarification of question 43, sample parent consents are available for SAP team use. These samples can be adjusted if needed; however, PNSAS staff believe this basic information will adequately address question 43. Also, the parent consent is generally sent home for signature following a telephone contact. At that time, teams usually send a SAP brochure along with the consent form. Please contact your Regional Coordinator if additional information is needed.

Sample parent consent form

Sample screening consent form


SAP Information Surveys:

Return to your Regional Coordinator

Liaisons survey letter – January 2012
Liaisons information survey – January 2012
Principals survey letter – January 2012
SAP Team information survey – January 2012
PNSAS map (contact information)

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About the Pennsylvania Student Assistance Program

The mission of the Pennsylvania Network for Student Assistance Services is to provide leadership for developing a safe and drug-free environment and mental health wellness in schools and communities across the commonwealth. Barriers to learning will be removed and student academic achievement will be enhanced through collaborative prevention, intervention, and post-intervention services. 

Now in its 27th year, SAP helps schools identify students who are experiencing behavior and or academic difficulties that are posing a barrier to their learning and success in school. SAP offers support to those students and their families.

Talking Points for 27 Years of SAP

Download the current SAP logo




More information about Student Assistance in Pennsylvania

Map of Pennsylvania Network for Student Assistance Services

What is SAP? The Commonwealth of Pennsylvania’s Student Assistance Program (SAP), which is administered by the PA Department of Education’s Division of School Options and Safety in partnership with the PA Department of Health’s Bureau of Drug and Alcohol Programs, and the PA Department of Public Welfare’s Office of Mental Health and Substance Abuse Services, is designed to assist school personnel in identifying issues including alcohol, tobacco, other drugs, and mental health issues which pose a barrier to a student’s success. More....