Teacher Survey (EDI)

Informed Consent, Teacher Survey (EDI)
INFORMED CONSENT FORM FOR RESEARCH PARTICIPATION
PROJECT LAUNCH TEACHER SURVEY (EDI)*
We are conducting a study to learn about the social and emotional development of children from birth to eight years of age.
This study is funded by the Substance Abuse and Mental Health Services Administration (SAMHSA), an agency within the
U.S. Department of Health and Human Services (HHS). By collecting information from kindergarten teachers in selected
schools, we seek to gain a better understanding of children's readiness to learn in five general domains: physical health and
well-being; social competence; emotional maturity; language and cognitive development; and communication skills.
If you choose to participate, you will be asked to fill out a survey for each child in your kindergarten class. To complete
the surveys for your entire class, we anticipate this will take approximately 10 hours to complete. As an incentive
for your participation, we will provide you with $50 for completing the survey.
There are no risks in participating in this research beyond those experienced in everyday life. However, some of the
questions are personal and may make you uncomfortable. Your participation in this study is voluntary. You can stop at
any time, and you do not have to answer any questions you do not want to answer. Refusal to take part in or withdrawing
from this study will not involve any penalty or loss of benefits you would receive otherwise.
Your responses will be kept private to the extent permitted by law. All findings will be reported in aggregate. If there
are any publications or presentations resulting from this research, no personally-identifiable information will be shared
because your name will not be linked to your answers. If you choose to withdraw from the study, we will maintain

and analyze the data collected up to the time of withdrawal. However, if you request that we destroy all of your
data and exclude your responses from the study results, we will honor your request.

Please contact Shannon TenBroeck, a member of the evaluation team at NORC, at (415) 315-2006 with questions,
complaints, or concerns about this research. If you have any questions about your rights as a research participant, please
contact the NORC Institutional Review Board (IRB) Manager by toll-free phone number at (866) 309-0542.
You must be 18 years of age or older to take part in this research study. If you agree to take part in this research study,
please sign your name and indicate the date below. You will be given a copy of this consent form for your records.
_____________________________________________
Participant Signature

_____________________
Date

* The informed consent will be incorporated into the web-survey. In lieu of a signature, respondents will be asked

to click an “I consent” button in the survey.

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. OMB number: 0970-0373;
Expiration date: XX/XX/XXXX

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EARLY DEVELOPMENT INSTRUMENT
A Population-Based Measure for Communities
42015
Please fill in the circles like
State ID
District ID
this
or X
NOT X
Please use a blue or black
ballpoint pen.
Please print in capital letters
& avoid contact with the
edge of the box.

A3 2

1. Classroom length/time:
Half-day a.m.
Half-day p.m.

Teacher or Class ID

EDI ID

6. Child has an Individualized
Education Program (IEP) or
equivalent?
Yes

Full day

No

Don't know

Other (specify)
2. Child's date of birth:
mm / dd /

yy

/

/

F

3. Sex:

M

4. Zip code:

-

7. Do you believe this child
has a special need?
Yes

No

8. Child has been referred for
assessment(s) to determine
if s/he qualifies for special
education services:
Yes

No

Don't know

5. Date of completion:
mm

/ dd /
-

0
1
2
3
4
5
6
7
8
9

yy
-

9. Child considered an English
Language Learner (ELL)?

Yes
No

©The Offord Centre for Child Studies, McMaster University, Hamilton Health Sciences Corporation
Licensed to the UCLA Center for Healthier Children, Families and Communities (310) 312-9083
Page 1

23938

10. What is the child's first language?

(See Guide for codes)

11. Does the child communicate

adequately in his/her first language:

Yes

No

Don't know

12. Is this year a repeat of
kindergarten for this child?

Yes

No

13. Child's race/ethnicity:

(See Guide for codes)

14. Student Status:

in class more than 1 month
in class less than 1 month
moved out of class

(Stop: End survey
here)

moved out of school
parents opted out
other, please specify

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Page 2

Section A - Physical Well-being
1.

Number of days
absent:

About how many regular days (see Guide) has this child been
absent since the beginning of the school year?

Number of days
sick:

2. How many of these days can be attributed to being sick?

Since the start of the school year, has this child
sometimes (more than once) arrived:

  3.

Yes

Don't
Know

over- or under-dressed for school-related activities

4.

too tired/sick to do school work

5.

late

6.

hungry

Would you say that this child:

No

7.

is independent in bathroom habits most of the time

8.

shows an established hand preference (right vs. left or vice versa)

9.

is well coordinated (i.e., moves without running into or tripping over things)

Sometimes teachers may observe that their students
are either underweight or overweight. Do you feel
that this child:

Yes

No

Don't
Know

Yes

No

Don't
Know

Poor/
Very Poor

Don't
Know

10. is underweight
11. is overweight

Very Good/
Good

How would you rate this child's:

Average

12. proficiency at holding a pen, crayons, or a paintbrush
13. ability to manipulate objects
14. ability to climb stairs
15. level of energy throughout the school day
16. overall physical development
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Section B - Language and Cognitive Skills
Very Good/
Good

How would you rate this child's:

 1.

Average

Poor/
Very Poor

ability to use language effectively

2.

ability to listen

3.

ability to tell a story

4.

ability to take part in imaginative play

5.

ability to communicate own needs in a way understandable to
adults and peers

6.

ability to understand on first try what is being said to him/her

7.

ability to articulate clearly, without sound substitutions

Would you say that this child:

Yes

Don't
Know

No

  8. knows how to handle a book (e.g., turn a page)
9.

is generally interested in books (pictures and print)

10. is interested in reading (inquisitive/curious about the meaning of printed material)
11. is able to identify at least 10 letters of the alphabet

  12. is able to attach sounds to letters

Don't
Know

13. is showing awareness of rhyming words
14. is able to participate in group reading activities
15. is able to read simple words
16. is able to read complex words
17. is able to read simple sentences
18. is experimenting with writing tools
19. is aware of writing directions (left to right, top to bottom)
20. is interested in writing voluntarily (and not only under the teacher's direction)
21. is able to write his/her own name
22. is able to write simple words
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Page 4

Section B - Language and Cognitive Skills
Would you say that this child:

Yes

No

Don't
Know

23. is able to write simple sentences
24. is able to remember things easily
25. is interested in mathematics
26. is interested in games involving numbers
27. is able to sort and classify objects by a common characteristic
(e.g., shape, color, size)
28. is able to use one-to-one correspondence
29. is able to count to 20
30. is able to recognize numbers 1 - 10
31. is able to say which number is bigger of the two

  32. is able to recognize geometric shapes (e.g., triangle, circle, square)
33. understands simple time concepts (e.g., today, summer, bedtime)
34. demonstrates special numeracy skills or talents
35. demonstrates special literacy skills or talents
36. demonstrates special skills or talents in arts
37. demonstrates special skills or talents in music
38. demonstrates special skills or talents in athletics/dance
39. demonstrates special skills or talents in problem solving in a creative way
40. demonstrates special skills or talents in other areas
(If yes, please specify:

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Page 5

Section C - Social and Emotional Development
Very Good/
Good

How would you rate this child's:
1.

overall social/emotional development

2.

ability to get along with peers

Average

Poor/
Very Poor

Don't
Know

Below is a list of statements that describe some of the feelings and behaviors of children. For each
statement, please fill in the circle that best describes this child now or within the past six months.
Would you say that this child:

Often or
Very True

3.

plays and works cooperatively with other children at the level
appropriate for his/her age

4.

is able to play with various children

5.

follows rules and instructions

6.

respects the property of others

7.

demonstrates self-control

8.

shows self-confidence

Sometimes or
Somewhat True

Never or
Not True

Don't
Know

  9. demonstrates respect for adults
10. demonstrates respect for other children
11. accepts responsibility for actions
12. listens attentively
13. follows directions
14. completes work on time
15. works independently
16. takes care of school materials
17. works neatly and carefully

 18. is curious about the world
19. is eager to play with a new toy
20. is eager to play a new game
21. is eager to play with/read a new book
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Section C - Social and Emotional Development
Often or
Very True

Would you say that this child:

Sometimes or
Somewhat True

Never or
Not True

22. is able to solve day-to-day problems by him/herself
23. is able to follow one-step instructions
24. is able to follow class routines without reminders
25. is able to adjust to changes in routines

26. answers questions showing knowledge about the world
(e.g., leaves fall in the autumn, apple is a fruit, dogs bark)
27. shows tolerance to someone who made a mistake (e.g., when a
child gives a wrong answer to a question posed by the teacher)
28. will try to help someone who has been hurt
29. volunteers to help clear up a mess someone else has made

  30. if there is a quarrel or dispute will try to stop it
31. offers to help other children who have difficulty with a task
32. comforts a child who is crying or upset

33. spontaneously helps to pick up objects which another child has
dropped (e.g., pencils, books)
34. will invite bystanders to join in a game
35. helps other children who are feeling sick
36. is upset when left by parent/guardian
37. gets into physical fights
38. bullies or is mean to others
39. kicks, bites, hits other children or adults
40. takes things that do not belong to him/her
41. laughs at other children's discomfort
42. can't sit still, is restless
43. is distractible, has trouble sticking to any activity
44. fidgets
45. is disobedient
46. has temper tantrums
47. is impulsive, acts without thinking
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Don't
Know

Section C - Social and Emotional Development
Often or
Very True

Would you say that this child:

Sometimes or
Somewhat True

Never or
Not True

Don't
Know

48. has difficulty awaiting turn in games or groups
49. cannot settle to anything for more than a few moments
50. is inattentive
51. seems to be unhappy, sad, or depressed
52. appears fearful or anxious
53. appears worried
54. cries a lot
55. is nervous, high-strung, or tense
56. is incapable of making decisions
57. is shy
58. sucks a thumb/finger or piece of clothing

Section D - Special Concerns
1. Does the student have a problem that influences his/her ability to do school work in a regular classroom
(based on parent information, medical diagnosis, and/or teacher observation)?
Yes
No (Skip to Section E)
Don't Know (Skip to Section E)

2. If YES above, please mark all that apply. Please base your answers on teacher observation and/or
parent guardian informationand/or medical diagnosis.
Yes, teacher
observed

Yes, parent
info/medical
diagnosis

Yes, teacher
observed

physical disability

home environment/problems at home

visual impairment

chronic medical/health problems

hearing impairment

unaddressed dental needs

speech impairment

homelessness

learning disability

other (if known, please print clearly)

Yes, parent
info/medical
diagnosis

emotional problem
behavioral problem

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Section D - Special Concerns
3. If the child has received a diagnosis or identification by a doctor or
psychological professional, please indicate. (See Guide for codes)

Not Applicable

4. Is the child receiving any school based support(s) (e.g., educational
assistant, equipment)?

Don't Know

Yes

Don't
Know

No

5. a) Do you feel that this child needs further assessment?
b) Is the child currently on a wait list to receive further assessment?

Section E - Additional Questions
To the best of your knowledge, please mark all that apply to this child:
1.

Has the child attended a special education preschool program or other early
intervention program/services (e.g., speech therapy)?
Specify type of program, if known:

2.

In the year prior to kindergarten entry, has the child been in non-parental child care
on a regular basis?

2a) If yes, please specify type of child care arrangement (see Guide): Mark all that apply.
Center-based

Yes

No

Don't
Know

Yes
No

(Skip to question 3)

Don't Know (Skip to question 3)

Child's home

Other (please specify

Other home-based (in someone else's home)

Don't Know (If No or Don't Know, skip to Question 3)

2b) To the best of your knowledge, in the year prior to the child's entry to
kindergarten, was the child care arrangement:
3.

Since the beginning of the school year, has the parent/guardian
volunteered in the classroom, on a classroom project, field trip, etc.?

4.

Has a parent/guardian attended at least one parent-teacher conference?

5.

Apart from parent-teacher conferences, have you had one-on-one conversations with
the student's parent/guardian (either by phone or face-to-face)?

)

Full-time Part-time

Yes

If you have any comments about this child and her/his readiness for school, please print them
below. **Please do not include the child's name below**

23938
© The Offord Centre for Child Studies, McMaster University, Hamilton Health Sciences Corporation
Licensed to the UCLA Center for Healthier Children, Families and Communities (310) 312-9083

Page 9

Don't
Know

No