Student LIC Assent Form

Student Assent Form

Student Assent Form

Lesson In Character Study

Dear Student,

You are being asked to participate in a survey that asks questions about you, your friends, and your school. Over the course of the study (2007-2009) you will be asked to complete similar forms and surveys such as this one. Each one should take about 35 minutes to complete.

This is not a test. There are no right or wrong answers and you will not be timed. The answers you give are very important. Please read each question carefully and answer it based on what you really know or do. Answer the questions truthfully and as best as you can.

The survey is anonymous and confidential. Do not put your names anywhere on the survey or the answer sheet. No one will ever be able to connect you with your answers. Your answers are private.

The survey is voluntary. You do not have to complete this survey, but we hope that you will.

Thank you.

Yes, I am willing to take the survey.

_________________________________________ ______________________

Print Your Name Date

Birth date: ___________________________________/________________/______________

Month Day Year

According to the Paperwork Reduction Act of 1995, no persons are required to respond to a collection of information unless such collection displays a valid OMB control number.  The valid OMB control number for this information collection is 1850-0826.  The time required to complete this information collection is estimated to average 35 minutes per response, including the time to review instructions, search existing data resources, gather the data needed, and complete and review the information collection.  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, D.C. 20202-4700.  If you have comments or concerns regarding the status of your individual submission of this form, write directly to:  Ok-Choon Park, U.S. Department of Education, 555 New Jersey Avenue, N.W., Room 506E, Washington, D.C. 20208.

Please remove this page carefully from the survey