Student Study Participation Agreement Form

Appendix G. REL Midwest CLC Study – Student Participation Form

Midwest Regional Educational Lab

Content Literacy Continuum Study

Study Participation Agreement Form - DRAFT

Your son/daughter’s high school is participating in a study of a program that provides literacy instruction across the daily high school curriculum.

The goal of this national study is to learn whether intensive literacy across the curriculum programs can improve students’ reading achievement and help them do better in high school. Only those students at whose parents agree to let them be part of the study will have a chance to participate in this study.

The U.S. Department of Education wants to protect the privacy of individuals who participate in surveys. Your answers will be combined with other surveys, and no one will know how you answered the questions. This survey is authorized by law (1) Sections 171(b) and 173 of the Education Sciences Reform Act of 2002, Pub. L. 107-279 (2002); and (2) Section 9601 of the Elementary and Secondary Education Act (ESEA), as amended by the No Child Left Behind (NCLB) Act of 2001 (Pub. L. 107-110).

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. The time required to complete this information collection is estimated to average 1 minute per respondent, including the time to review instructions, gather the data needed, and complete and review the information collected. If you have any comments concerning the accuracy of the time estimate(s) or suggestions for improving this form, please write to: U.S. Department of Education, Washington, DC 20202. If you have comments or concerns regarding the status of your individual submission of this form, write directly to: U.S. Department of Education, Institute of Education Sciences, 555 New Jersey Avenue, NW, Washington, DC 20208.

To be part of the CLC study, parents and students must understand the following:

• As part of the study, your son/daughter will be asked to take a reading test at the end of the school year. No student has to answer questions that he/she does not want to answer.

• For students participating in the study, the study will collect information from school records during their high school careers. This will include information such as students’ grades, attendance, free/reduced-price lunch status, and test scores.

• All information about your son/daughter will be kept confidential to the extent allowable by law and used only for the study and related research. Responses to this data collection will be used only for statistical purposes. The reports prepared for this study will summarize findings across the sample and will not associate responses with a specific district or individual. We will not provide information that identifies you or your district to anyone outside the study team, except as required by law.

Please indicate YES or NO with an X in the box below.
[ ] YES, I would like my child to participate in the CLC program and I give permission for my child to participate in this study.	[ ] NO, I do not give permission for my child to participate in this study.

Print Name of Parent/Guardian: ___________________________________________________

Parent/Guardian Signature: _______________________________________________________

Phone Number: (______) _____________________ Date: _____________________________

Print Name of Student: _________________________________________________________

Student Signature: _____________________________________________________________

Student Birthdate: _____/_____/_________ Student ID Number: ________________________

Sponsored by the U.S. Department of Education OMB #: TBD

Conducted by LPA and MDRC Expiration: TBD

Study Director: James Kemple, MDRC, phone (212) 532-3200 Version: 07/05/07