2007-2008 & 2008-2009 Research Participant Consent Form:

OMB Number: xxxx-xxxx

Expiration Date: xx/xx/07

Appendix Z

Research Participant Consent Form: Professional Development Trainer Log

UNIVERSITY OF NORTH CAROLINA AT GREENSBORO

Professional Development Trainer Log

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 5¹ minutes per daily log, 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 on which he or she is providing training to teachers. The participant is being asked to complete brief daily training logs. The purpose of the logs is to understand what content is covered and what instructional strategies are used in the training and the benefits of the training on participants, not to evaluate individual trainers. The logs should take no more than 5 minutes to complete each day.

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

POTENTIAL BENEFITS: It may be that completing training logs will give the participant the opportunity to reflect upon his or her delivery of the training. This increased reflectivity thus may be a positive benefit. In addition, a sense that the system cares enough about what trainers are doing with AMSTI to send an evaluator is probably reassuring to them. And, in general, the trainer logs will permit AMSTI researchers to understand the nature of AMSTI professional development 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 training logs.

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 training logs. 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 Richard Sawyer at 202-884-8868 or Denis Newman at 1-888-486-8886 x 127. 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

1 The estimate of 5 minutes for information collection is based on completion of the Daily Trainer Log at the end of each day. The Professional Development Trainer Background Sheet only needs to be completed by you once, on which occasion, the estimated time for information collection will be a total of 15 minutes.

2

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egional Educational Laboratory