Attachment E Consent form for program staff

ATTACHMENT E

CONSENT FORM FOR PROGRAM STAFF

THE Examining data informing teaching (EDIT) development Project

consent form FOR program staff

What is the purpose of the research study?		The purpose of the study is to develop a new research tool to help us learn how teachers assess children in their classrooms and use the information to tailor classroom instruction. The project is sponsored by the Administration for Children and Families in the U.S. Department of Health and Human Services.
Who is being invited to participate in the research study?		The pretest of the new tool will involve teachers and children in 9 early childhood classrooms. Participation is voluntary; refusal to participate in the study will not negatively affect your relationship with your program. Even if you agree to participate in the study, you may withdraw at any time.
When will the research study be conducted?		The study activities in which we are asking teachers and children to participate will take place from October 2015 to May 2016.
	What will be asked of parents and staff who agree to participate?	If you agree to participate, you will: (1) video-record yourself collecting assessment information for two children and instructing children in small groups, (2) gather assessment and instruction information about two children, (3) participate in an interview about your use of assessment information to tailor instruction for children in your classroom and (4) complete a brief questionnaire about your background and classroom. You will also be invited to participate in a brief phone call to talk about your experiences with the study. All the information we collect will be used for research and educational purposes only. You can skip any interview questions you prefer not to answer. All of these activities combined will take you less than four hours.
	How will participants be thanked?	Based on your program’s policies, we would like to give you a gift card valued at $75 to be used for the classroom, as a token of our appreciation. Each participating early childhood program will also receive $50. If you participate in the additional brief phone call, a $20 gift card will be provided.
	Who is conducting the research study?	Mathematica Policy Research is conducting the study for the Administration for Children and Families. Mathematica is a nationally recognized, nonpartisan research organization that conducts studies in early childhood education and other public policy areas. Additional information about Mathematica can be found online at http://www.mathematica-mpr.com.

How will Mathematica protect the privacy of research study participants?	Mathematica is committed to respecting the privacy of everyone who contributes to this study. A code number will be used on all information we collect from you so that you cannot be identified. Should you agree to take part in the study, all information you share will remain private to the extent permitted by law. No one from your program will see or hear your individual responses, and your name will never be associated with or identified in study reports.
How can I get more information about the research study?	If you have any questions or would like more information about the study, please contact Shannon Monahan at Mathematica at 609‑275‑2207, or via email at [email protected].
An agency may not conduct or sponsor, and a person is not required to respond to, a collection of information unless it displays a currently valid OMB control number. The OMB control number for this collection is 0970-0355 and it expires 03/31/2018. Please read the following statements, check the appropriate box, and complete the bottom section.  Yes, I wish to participate in this study. I agree that the study team members may review the data I collect about children in my classroom and may view the video-recording that I take of myself. I understand this video-recording may be used for research and educational purposes and give permission for its use. I will receive no proceeds or compensation for the use of the video-recording for these research or educational purposes or for the research tool’s future revisions, editions, translations, adaptations, and other formats. I understand that I may choose not to answer specific questions on the questionnaire or asked during my one-on-one interview by simply stating “Pass” or “I prefer not to answer.” I understand that the one-on-one interview will be audio-recorded. The information I provide during my interview may be directly quoted in order to illustrate a point, but any specific names or places that I mention will be omitted. I may withdraw this consent at any time. I understand that my responses will not be associated with me personally in any way. The videos and recordings will be stored by Mathematica until the project ends and they are no longer required, at which time they will be destroyed. I have read this form and have received a copy for my records.  No, I do not wish to participate in this study. I have read this form and have received a copy for my records. Printed Name Signature Date
P.O. Box 2393 Princeton, NJ 08543 609-799-3535