Research Participant Consent Form: Professional Developm

OMB Number: xxxx-xxxx

Expiration Date: xx/xx/07

Appendix AA

Research Participant Consent Form: Professional Development Participant Survey

UNIVERSITY OF NORTH CAROLINA AT GREENSBORO

Professional Development Participant Survey

CONSENT TO ACT AS A HUMAN PARTICIPANT

Project Title: The Evaluation of the Alabama Math, Science and Technology Initiative

Co-PIs: Dr. Richard Sawyer, Dr. Denis Newman

Participant's Name: ­­­­­­­­­­­­­­­­­_____________________________

The collection of information in this study is authorized by Public Law 107-279 Education Sciences Reform Act of 2002, Title I, Part C, Sec. 151(b) and Sec. 153(a). Participation is voluntary. You may skip questions you do not wish to answer; however, we hope that you will answer as many questions as you can. Your responses are protected from disclosure by federal statute (PL 107-279 Title I, Part C, Sec. 183). All responses that relate to or describe identifiable characteristics of individuals may be used only for statistical purposes and may not be disclosed, or used, in identifiable form for any other purpose, unless otherwise compelled by law. Data will be combined to produce statistical reports. No individual data that links your name, school name, address, telephone number, or identification number with your responses will be included in the statistical reports.

According to the Paperwork Reduction Act of 1995, no persons are required to respond to a collection of information unless it displays a valid OMB control number.  The valid OMB control number for this information collection is XXXX-XXXX (expiration date: XX/XX/07).  The time required to complete this information collection is estimated to average 10 minutes, including the time to review instructions, search existing data resources, gather the data needed, and complete the information collection.  If you have any comments concerning the accuracy of the time estimate or suggestions for improving this form, please contact: the Department of Education 50 North Ripley Street PO Box 302101 Montgomery, AL 36104.  If you have comments or concerns regarding the status of your individual submission, e-mail directly to: [email protected].

DESCRIPTION AND EXPLANATION OF PROCEDURES: The purpose of the evaluation is to assess, through a randomized controlled experiment, whether AMSTI has a positive effect on classroom practice and student test scores. The participant has been selected to be part of the study based upon the grade and subject which he or she is teaching. The participant is being asked to complete a survey of his or her experiences in the training. The purpose of the survey is to understand what is covered in the training and the benefits of the training on participants, not to evaluate individual teachers or trainers. The survey should take no more than 10 minutes to complete.

RISKS AND DISCOMFORTS: It is not anticipated that there will be any risk or discomfort associated with completing the survey.

POTENTIAL BENEFITS: It may be that completing a survey about the course will give the participant the opportunity to reflect on the session. This increased reflectivity thus may be a positive benefit. In addition, a sense that the system cares enough about what teachers are doing with AMSTI to send an evaluator is probably reassuring to them. And, in general, the participant survey will permit AMSTI researchers to understand the nature of AMSTI training, and fidelity to the policy and program goals of AMSTI.

COMPENSATION/TREATMENT FOR INJURY: There is no risk of injury as a result of completing the survey.

CONSENT: By signing this consent form, the participant agrees that he/she understands the procedures and any risks and benefits involved in this research. He/she is free to refuse to participate or to withdraw consent to participate in this research at any time without penalty or prejudice; his/her participation is entirely voluntary. He/she is also free to ask any questions, either before or after completing the survey. His/her privacy will be protected because his/her identity will not be disclosed, except to researchers involved in the project, and any reports or publications that result from the study will be written to prevent his/her being individually identifiable, or for his/her school being individually identifiable. All data from this survey will be retained under secure conditions for a maximum of ten years and then destroyed by shredding.

The University of North Carolina at Greensboro Institutional Review Board, which insures that research involving people follows federal regulations, has approved the research and this consent form. Questions regarding participant rights in this project can be answered by calling Mr. Eric Allen at (336) 256-1482. Questions regarding the research itself can be answered either by calling Denis Newman at 1-888-486-8886 x 127 or Richard Sawyer at (202) 884-8868. Any new information that develops during the project will be provided to the participant if the information might affect his/her willingness to continue participation in the project.

Signing this form signifies agreement to participate in the project.

____________________________________ ______________

Participant's Signature* Date

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