Impact Study of Feedback for Teachers Based on Classroom Videos

APPENDIX E
ACTIVE AND PASSIVE PARENT PERMISSION FORMS

This page has been left blank for double-sided copying.

OMB Number: [XXXXXX]
Expiration Date: [XXXXX]

P.O. Box 2393
Princeton, NJ 08543-2393
Phone: 609-799-3535
Fax: 609-799-0005

ACTIVE PARENT PERMISSION

[month] [year]

Dear Parent or Guardian,
The Institute of Education Sciences (IES) in the U.S. Department of Education is sponsoring a study aimed at
improving teachers’ instruction by providing feedback to teachers based on multiple video recordings of their
teaching. This requires that teachers be recorded in their classroom while teaching actual classes.
The U.S. Department of Education selected Mathematica Policy Research to lead this study. Mathematica is a
nonpartisan research firm that designs studies, collects data, and conducts analysis for the federal and state
governments, foundations, and the private sector.
I am writing to request permission for your child to be included in the video recordings of his or her teacher’s
classes, which will take place 6 to 15 times during the school year.
Please know that:
 your child’s identity, as well as that of other students, schools, and teachers will be kept confidential;
 video recordings will only be used for assessing teacher instruction and to help teachers improve
their practices; they will not be used to evaluate any student’s performance;
 video recordings will only be viewed by the study team; and
 video recordings will be destroyed at the end of the study.
Students are not the focus of the recordings, but interactions between the teacher and some students may be
captured in the recordings. All information you provide will be kept strictly confidential and will not be shared
with anyone outside the study team, and neither your name nor your child’s name will be identified in any
study reports.
A trained study team member will conduct the video recordings. They will make every effort to avoid
disrupting the class and only about 30 minutes of instruction will be video recorded on each visit. Allowing
your child to be included in these recordings is voluntary; refusing permission will in no way affect your
child’s grade.
If you allow your child to be included in these recordings, you or your child can choose to stop participation at
any time with no consequences. If you do not allow your child to be included in the recordings, we will ask the
teacher to seat your child outside the range of the camera while the classroom is being recorded.
Please let us know whether you will allow your child to be included in the study recordings of his or her
teacher’s class by completing the attached pink form. If you give your permission for your child to be included
in the recordings, please check “yes” and sign the attached pink form, and have your child return it to his or her
teacher by [month] [day]. Please keep the blue form and this letter for your records. If you have questions
about this study or about your child's participation, please call Sheila Heaviside, Mathematica's Survey
Director, toll-free, at [1-XXX-XXX-XXXX] between 9 a.m. and 5 p.m. Eastern Standard Time, MondayFriday or email the study team at [xxxxx]. For more information about Mathematica, please visit our website
at www.mathematica-mpr.com.
Sincerely,
Susanne James-Burdumy, Ph.D.
Project Director
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 xxxx-xxxx. The time required to
complete this information collection is estimated to average 15 minutes, including the time to review instructions, search existing data
sources, gather the data needed, and complete and review the parent permission form. If you have any comments concerning the accuracy
of the time estimate or suggestions for improving this form, please write to: U.S. Department of Education, Washington, DC 20202. If you
have comments or concerns regarding the content or the status of your individual submission of this form, write directly to: U.S. Department
of Education, Institute of Education Sciences, 550 12th Street, SW, Washington, DC 20202.

An Affirmative Action/Equal Opportunity Employer

ACTIVE PARENT PERMISSION FORM
Impact Study of Feedback for Teachers Based on Classroom
Videos
VIDEO RECORDING PARENT PERMISSION FORM
[Month] [Year]

Please complete the following form and have your child return it to his/her teacher by [day of
week] [month] [day].
I have read the attached information sheet describing the study. By signing this form, I am
saying:
YES, I give my permission for my son/daughter to be included in the video
recordings of his or her teacher’s 4th or 5th grade class by Mathematica Policy
Research.
OR
NO, I do not give permission for my son/daughter to be included in video
recordings of his or her teacher’s 4th or 5th grade class by Mathematica Policy
Research. I request that my child be seated outside the range of the camera while
the class is being video recorded.
YOUR CHILD’S NAME

YOUR CHILD’S TEACHER’S NAME

PARENT OR GUARDIAN SIGNATURE

DATE

PARENT OR GUARDIAN NAME (PLEASE PRINT)
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 xxxx-xxxx. The time required to
complete this information collection is estimated to average 15 minutes, including the time to review instructions, search existing data
sources, gather the data needed, and complete and review the parent permission form. If you have any comments concerning the accuracy
of the time estimate or suggestions for improving this form, please write to: U.S. Department of Education, Washington, DC 20202. If you
have comments or concerns regarding the content or the status of your individual submission of this form, write directly to: U.S. Department
of Education, Institute of Education Sciences, 550 12th Street, SW, Washington, DC 20202.

OMB Number: [XXXXXX]
Expiration Date: [XXXXX]

P.O. Box 2393
Princeton, NJ 08543-2393
Phone: 609-799-3535
Fax: 609-799-0005

PASSIVE PARENT PERMISSION

[month] [year]

Dear Parent or Guardian,
The Institute of Education Sciences (IES) in the U.S. Department of Education is sponsoring a study aimed at
improving teachers’ instruction by providing feedback to teachers based on multiple video recordings of their
teaching. This requires that teachers be recorded in their classroom while teaching actual classes.
The U.S. Department of Education selected Mathematica Policy Research to lead this study. Mathematica is a
nonpartisan research firm that designs studies, collects data, and conducts analysis for the federal and state
governments, foundations, and the private sector.
Your child’s classroom will be video recorded 6 to 15 times during the school year.
Please know that:
 your child’s identity, as well as that of other students, schools, and teachers will be kept confidential;
 video recordings will only be used for assessing teacher instruction and to help teachers improve
their practices; they will not be used to evaluate any student’s performance;
 video recordings will only be viewed by the study team; and
 video recordings will be destroyed at the end of the study.
Students are not the focus of the recordings, but interactions between the teacher and some students may be
captured in the recordings. All information you provide will be kept strictly confidential and will not be shared
with anyone outside the study team, and neither your name nor your child’s name will be identified in any
study reports.
A trained study team member will conduct the video recordings. They will make every effort to avoid
disrupting the class and only about 30 minutes of instruction will be video recorded on each visit. Allowing
your child to be included in these recordings is voluntary; refusing permission will in no way affect your
child’s grade. If you allow your child to be included in these recordings, you or your child can choose to stop
participation at any time with no consequences. If you do not allow your child to be included in the recordings,
we will ask the teacher to seat your child outside the range of the camera while the classroom is being
recorded.
If you do NOT choose to give permission for your child to be included in the study recordings of his or her
teacher’s class, please complete the attached pink form and have your child return it to his or her teacher by
[month] [day]. Please keep the blue form and this letter for your records. If you have questions about this study
or about your child's participation, please call Sheila Heaviside, Mathematica's Survey Director, toll-free, at
[1-XXX-XXX-XXXX] between 9 a.m. and 5 p.m. Eastern Standard Time, Monday-Friday or email the study
team at [xxxxx]. For more information about Mathematica, please visit our website at www.mathematicampr.com.
If you give permission for your child to be included in the study recordings of his or her teacher’s class, you do
not need to return any forms (you can just retain them for your records).
Sincerely,
Susanne James-Burdumy, Ph.D.
Project Director
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 xxxx-xxxx. The time required to
complete this information collection is estimated to average 15 minutes, including the time to review instructions, search existing data
sources, gather the data needed, and complete and review the parent permission form. If you have any comments concerning the accuracy
of the time estimate or suggestions for improving this form, please write to: U.S. Department of Education, Washington, DC 20202. If you
have comments or concerns regarding the content or the status of your individual submission of this form, write directly to: U.S. Department
of Education, Institute of Education Sciences, 550 12th Street, SW, Washington, DC 20202.

PASSIVE PARENT PERMISSION FORM
Impact Study of Feedback for Teachers Based on Classroom
Videos
VIDEO RECORDING PARENT PERMISSION FORM
[SCHOOL ID-STUDENT MPRID]

[Month] [Year]
Please complete and sign the following form if you do not give your permission to allow your
child to be included in video recordings. Please have your child return it to his/her teacher by
[day of week] [month] [day].
I have read the attached information sheet describing the study. By signing this form, I am
saying:
NO, I do not give permission for my son/daughter to be included in video
recordings of his or her teacher’s 4th or 5th grade class by Mathematica Policy
Research. I request that my child be seated outside the range of the camera while
the class is being video recorded.
YOUR CHILD’S NAME

YOUR CHILD’S TEACHER’S NAME

PARENT OR GUARDIAN SIGNATURE

DATE

PARENT OR GUARDIAN NAME (PLEASE PRINT)

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 xxxx-xxxx. The time required to review
this request and to complete this information collection is estimated to average 15 minutes, including the time to review instructions, search
existing data sources, gather the data needed, and complete and review the parent permission form. If you have any comments concerning
the accuracy of the time estimate or suggestions for improving this form, please write to: U.S. Department of Education, Washington, DC
20202. If you have comments or concerns regarding the content or the status of your individual submission of this form, write directly to:
U.S. Department of Education, Institute of Education Sciences, 550 12th Street, SW, Washington, DC 20202.