Parent Consent/Survey

Appendix B: Parent Consent Form

Revised May 6, 2011

National Evaluation of the National Aeronautics and Space Administration (NASA)’s Summer of Innovation

NASA Office of Education is instituting a program called Summer of Innovation for middle school students. Two research companies—Abt Associates and the Education Development Center—were hired to do the national evaluation. The evaluation will include more than 25,000 students across the country. NASA Office of Education is asking some of the students participating in the Summer of Innovation program to complete brief voluntary surveys. These surveys will ask students about their leisure and career interests in science and about participation in voluntary science activities.

What it Means to Participate

Students participating in the study will be asked to fill out a survey three times over the next year: at the start and end of this summer’s camp activities and by mail in spring 2012. The surveys will help us improve the Summer of Innovation program and we greatly value the feedback. However, your child’s participation is voluntary. Whether your child is part of the study will not affect whether he or she is eligible for any program or service. If you give permission, your child will be asked to fill out three brief surveys once this spring before the program starts, again when the summer activities end this summer and again by the end of the school year. Your child does not have to answer any question he or she does not want to. All information collected will be used only for research purposes.

Securing Your Child’s Responses

Protecting your child’s privacy is very important to us. NASA Office of Education, the companies doing the study, and the program’s staff will follow strict rules to protect your child’s privacy. Your child’s name, and the name of your child’s school, or the name of your child’s Summer of Innovation program, will not appear in any reports produced for this study. Your child’s answers will be kept hidden from the program staff, NASA, your child’s school staff and friends. Your child’s name will be replaced with an identification number for the purpose of this study. Any information on your child entered into a database will be stored on a secure computer network. Paper copies of your child’s survey responses will also be stored securely. We will not provide information that identifies your child to anyone outside the study team and the Summer of Innovation staff, except as required by law.

As with all data collection, there is a very small chance that someone will see your child’s survey answers without permission. NASA Office of Education, the Summer of Innovation staff, and the study team have many procedures in place to protect the privacy of the data collected on your child, so we do not think this will happen. However, if it does, all NASA Office of Education procedures will be followed to correct the situation.

Questions About the Study

If you have any questions about the survey, please email the research team at [email protected] or call Dr. Hilary Rhodes, Study Director, at

877-520-6840 (toll-free). For questions about your child’s rights as a participant in this evaluation, please contact Abt’s Institutional Review Board Administrator, Dr. Teresa Doksum 877-520-6835 (toll-free).

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 will be entered after clearance. The time required to complete this information collection is estimated to average 5 minutes per response, including the time to review instructions, search existing data resources, gather the data needed, and complete and review the information collection.

1. Please read the following statement. NASA Summer of Innovation program to which your child is applying is participating in a national study. This NASA study is being conducted by Abt Associates and Education Development Center. The purpose of the study is to learn how Summer of Innovation helps students develop interest in science, technology, engineering, and math. We ask your permission to collect survey information from your child at the start and the end of the summer camp activities, and once by mail in spring 2012. The surveys will ask your child about his or her attitude towards science as well as their leisure and career interest in science. Participation in this study is voluntary and your decision of whether or not to provide permission will not affect your child’s eligibility for the program. Your child’s survey data will be kept strictly private to the extent allowed by law and will be used ONLY for the purpose of the study. 2. After reading the above statement, do you give permission for your child to participate in the National Evaluation of NASA’s Summer of Innovation?
	YES, my child __________________________________________________________________________
	First Name Last Name has my permission to participate in the national evaluation of NASA’s Summer of Innovation.
	NO, my child __________________________________________________________________________
	First Name Last Name Does not have my permission to participate in the national evaluation of NASA’s Summer of Innovation.
Print Your Name: First Name Last Name
Signature: Date:
Student’s mailing address: ___________________________________________________________________ City:___________________________ State:_____________________ Zip code: _______________________
Email address:__________________________		Telephone:__________________________________

Please turn to next page

1. What is your child’s birthday?

Month: ________ Day:__________________

2. What school will your child attend in fall 2011? ____________________________________

3. What grade level will your child enter in fall 2011?

4^th 5^th 6^th 7^th 8^th 9^th Other:______________

4. What is your child’s gender?

Male Female

5. What is your child’s ethnicity? Please check one only.

 Hispanic or Latino

 Not Hispanic or Latino

6. What is your child’s race? Please check one or more.

American Indian or Alaska Native

Asian

Black or African American

Native Hawaiian or Other Pacific Islander

White

7. At any point during the previous school year, did your child receive free or reduced price lunch?

Yes/free Yes/reduced No Don’t know

8. What is the highest level of education which you have completed?

Less than 9^th grade

Some high school, but did not graduate

High school degree

GED or equivalent

Some college, no degree

Associates degree

Bachelors degree

Masters degree

Professional degree or doctorate

9. Why is your child attending this program? Please check one or more.

 Student needs summer supervision

 Student is interested because friends are attending

 Student is interested because of the science enrichment activities offered

 Parent is interested in science enrichment programs

 Teacher recommended program

 Student needs assistance in science

 Additional reasons for attending the program:_________________

We have a few additional questions that we would like to complete about your child.

Child’s First and Last Name: ­­

National Aeronautics and Space Administration - Summer of Innovation Appendix B-0