Form DoDEA Form 2071.3- DoDEA Form 2071.3- Research Study Request

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RESEARCH STUDY REQUEST

The public reporting burden for this collection of information is estimated to average 60 minutes per response, including the time for reviewing instructions, searching existing data sources, gathering
and maintaining the data needed, and completing and reviewing the collection of information. Send comments regarding this burden estimate or any other aspect of this collection of information,
including suggestions for reducing the burden, to the Department of Defense, Executive Services Directorate, Information Management Division, 1155 Defense Pentagon, Washington, DC 20301-1155
(####-####). Respondents should be aware that notwithstanding any other provision of law, no person shall be subject to any penalty for failing to comply with a collection of information if it does not
display a currently valid OMB control number.

PLEASE DO NOT RETURN YOUR FORM TO THE ABOVE ORGANIZATION. RETURN COMPLETED FORM TO:
DoD Education Activity, Research and Evaluation Branch, 9th Floor, 4040 N. Fairfax Drive, Arlington, VA 22203
PRIVACY ACT STATEMENT
AUTHORITY: Sections 10 U.S.C. 113, Secretary of Defense; 10 U.S.C. 2164, Department of Defense Elementary and Secondary Schools; and 20
U.S.C. 921-932, Overseas Defense Dependent's Education.
PRINCIPAL PURPOSE(S): To maintain a case file for use by management concerning any research project undertaken concerning DoDEA students,
parents/sponsors, faculty or staff; and to permit identification and tracking of authorized research projects and researchers.
ROUTINE USE(S): In addition to disclosures generally permitted under 5 U.S.C. 552a(b) of the Privacy Act, these records or information contained
therein may specifically be disclosed under the DoD "Blanket Routine Uses" set forth at the beginning of the OSD's compilation of systems of records
notices.
DISCLOSURE: Voluntary; however, failure to disclose the information may prevent individuals from conducting research involving DoDEA.
1. NAME (Last, First, Middle Initial)

2. DATE (YYYYMMDD)

3. ADDRESS (Include ZIP Code)

4. TELEPHONE NUMBERS (Include Area Code)
a. HOME

b. WORK

5. FAX NUMBER (Include Area Code)

6. E-MAIL ADDRESS

7. ARE YOU CURRENTLY EMPLOYED BY THE DEPARTMENT OF DEFENSE EDUCATION ACTIVITY?
YES
IF YES, WHAT IS YOUR CURRENT ASSIGNMENT (School and District)
NO
8. TITLE OF RESEARCH

9. PROPOSAL ABSTRACT

D R A F T

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10. EXPLAIN HOW YOUR RESEARCH STUDY (1) IS ALIGNED WITH THE DEPARTMENT OF DEFENSE EDUCATION ACTIVITY (DoDEA)
COMMUNITY STRATEGIC PLAN, AND (2) WILL BENEFIT DoDEA.

D R A F T

11. WHAT IS (ARE) THE RESEARCH QUESTIONS OR MAJOR HYPOTHESIS TO BE TESTED?

12. DESCRIBE THE POPULATION AND/OR SAMPLE TO BE STUDIED.
(1) SAMPLE
(2) NUMBER
(3) DESCRIPTION (Grades, Schools, Demographics)

a. STUDENTS

b. ADMINISTRATION

c. STAFF/OTHERS

d. SPONSORS/
GUARDIANS

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13. DESCRIBE YOUR PLANS FOR CONDUCTING THE STUDY INCLUDING ADMINISTRATION OF INSTRUMENTS, OTHER DATA
COLLECTION ACTIVITIES, AND THE TIMETABLE YOU WILL FOLLOW. (Include a copy of all questionnaires, surveys, exams, interview
protocols, etc. you plan to use.)
(1) PARTICIPANTS

(2) INSTRUMENT/
TYPE OF DATA COLLECTED

(3) AMOUNT OF TIME
REQUIRED

(4) TIMELINE

a. STUDENTS

b. ADMINISTRATION

c. STAFF/OTHERS

d. SPONSORS/
GUARDIANS
14. DESCRIBE WHAT, IF ANY, SPECIFIC RESOURCES YOU WILL NEED FROM DoDEA (e.g. materials, room, mailbox, etc.).

D R A F T
15. IF REQUESTING DATA FROM DoDEA, DESCRIBE IN DETAIL THE DATA YOU ARE REQUESTING (e.g. demographics, sample size,
specific measures, etc.).

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16. FOR EACH RESEARCH QUESTION LISTED, DESCRIBE IN DETAIL THE SPECIFIC ANALYTIC PROCEDURES THAT WILL BE USED.

D R A F T

17. IN WHAT FORM(S) AND TO WHOM WILL YOU REPORT YOUR FINDINGS?

18. DATE COLLABORATIVE INSTITUTIONAL TRAINING INITIATIVE (CITI) TRAINING WAS COMPLETED
(YYYYMMDD)
19. ATTACHMENTS (X all the items below which you are attaching to this application.)
A COPY OF THE INSTITUTIONAL REVIEW BOARD (IRB) FOR HUMAN SUBJECTS (Required).
CONSENT FORMS (Required if study includes data collected from human subjects).
INSTRUMENTS TO BE USED (Surveys, interview questions, observation forms, etc.) (Required if used in study).
OTHER (Specify):

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