Sample Screener

OMB NO: XXXX-XXXX
App. Exp: xx/xx/xxxx

Early Childhood Longitudinal Study - Birth
Cohort (ECLS-B)
Fall 2007 School Enrollment and Address
Information Update for Twins
Prepared for the U.S. Department of Education
National Center for Education Statistics
by RTI International
3040 Cornwallis Road
Research Triangle Park, NC 27709
(919) 541-6000

Assurance of Confidentiality
The collection of information in this survey is authorized by Public Law 100 -297 and
continued under the auspices of Section 404(a) of the National Education Statistics Act of
1994, Title IV of the Improving America's Schools Act of 1994, Public Law 103 -382.
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. No information collected under this
authority may be used for any purpose other than the purpose for which it was supplied.
Information will be protected from disclosure by federal statute (42 US Code 242m, section
308d). Data will be combined to produce statistical reports. No individual data that links your
name, address, telephone number, or identification number with your responses will be
reported. There is one exception. Under the USA Patriot Act of 2001, the Attorney General of
the United States could get information collected in this study under court order to use to
investigate and prosecute acts of terrorism.
If you have any questions about your rights as a research subject in this study, please call the
office of the Research Ethics Review Board at the National Center for Health Statistics, toll
free at 1-800-223-8118. Please leave a brief message with your name and phone number.
Say that you are calling about Protocol #2004-08. Your call will be returned as soon as
possible.

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SECTION A. School Enrollment for {CHILD'S FIRST NAME
PRELOADED}
Please check one box for each question below.
Q1.

Is your child enrolled in school this year, meaning the 2007-2008 school year?
YES………………………………………….
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Q2.

Do you plan to enroll your child in school for the 2007-2008 school year?
YES………………………………………….
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Q3.

What grade is your child going to be in this school year? Please check one.
PRESCHOOL………………………………………….
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KI
NDERGARTEN.
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RSTGRADE.
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SECONDGRADE.
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OTHER………………………………………….
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Please
describe other grade

Continue with Section B below.

Section B. School Enrollment for {TWIN}
Please check one box for each question below.
Q4.

Is your child enrolled in school this year, meaning the 2007-2008 school year?
YES………………………………………….
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Q5.

Do you plan to enroll your child in school for the 2007-2008 school year?
YES………………………………………….
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Q6.

What grade is your child going to be in this school year? Please check one.
PRESCHOOL………………………………………….
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KI
NDERGARTEN.
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FI
RSTGRADE.
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SECONDGRADE.
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OTHER………………………………………….
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Please
describe other grade
57459

Please go to next page.

Contact Information Update
Please review the information printed below.
If your address and telephone number are correct, pl
eas
echec
kt
he“
Cont
ac
tI
nf
or
mat
i
on
Is Cor
r
ect
”boxat the bottom of the page.
If your information has changed, please cross through anything that is incorrect and write
your new information in the space provided next to it.
If you plan to move and know your new address and telephone number, please enter it
in the space provided below.
If you plan to move and do not know your new address and telephone number, please
provide an address or phone number that we can use to reach you (for example, a work
number, a cell phone number, or a friend who always knows how to reach you).

CURRENT CONTACT INFORMATION

UPDATED CONTACT INFORMATION

[PANEL_INFO ID]

[R_FIRST NAME] [R_LAST NAME]
[ADDRESS LINE 1]
[ADDRESS LINE 2]
[CITY], [STATE] [ZIP]
TELEPHONE: [TELEPHONE]
CHILD'S NAME: [CHILD'S NAME]
TWIN'S NAME: [TWIN'S NAME] {IF TWIN CASE}

If you are moving, on what date do you expect to
move to the new address?

/
MONTH /

CONTACT INFORMATION IS CORRECT

/
DAY

/ YEAR

Thank You!

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