DoDEA Form 2071.3- Research Study Request

OMB No. 0704-0457
OMB approval expires

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, 4800 Mark Center Drive, Alexandria, VA 22350-3100
(####-####). 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: Title 10 U.S.C. 2164, Department of Defense Elementary and Secondary Schools; and Title 20 U.S.C. 921-932, Department of
Defense Dependents Schools; and DoD Directive 1342.20, Department of Defense Education Activity.
PRINCIPAL PURPOSE(S): To enable DoDEA management to identify and track authorized research projects and researchers concerning any
research project undertaken concerning DoDEA students, parents/sponsors, faculty or staff.
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 outside the DoD as a routine use pursuant to 5 U.S.C. 552a(b)(3) and the DoD Blanket Routine Uses, described
at: http://dpclo.defense.gov/privacy/SORNs/blanket_routine_uses.html/ and the DoDEA routine uses at:
http://dpclo.defense.gov/privacy/SORNs/component/osd/DODEA27.html.
DISCLOSURE: Voluntary; however, failure to disclose the information may prevent individuals from conducting research involving DoDEA.
1. NAME (Last, First, Middle Initial)

3. ADDRESS (Include ZIP Code)

2. DATE (YYYYMMDD)

D R A F T

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

DoDEA FORM 2071.3-F1, 20111229 DRAFT

PREVIOUS EDITION IS OBSOLETE.

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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? (List and number each research question
separately.)

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. (List
and number each analytic procedure separately. Numbers should correspond to the research questions listed in item 11.)

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):

DoDEA FORM 2071.3-F1, 20111229 DRAFT

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