School-Day Teacher Survey

Appendix I:
School-Day Teacher Survey

OMB No.: xxxx-xxxx Expiration Date: xx/xx/xxxx

U.S. DEPARTMENT OF EDUCATION

National Study of Continuous Quality Improvement to Inform the 21st Century Community Learning Centers Program

School-Day Teacher Survey

October 2021

This questionnaire is part of the National Study of Continuous Quality Improvement to Inform the 21st Century Community Learning Centers Program, a national evaluation being conducted for the U.S. Department of Education by Mathematica. The questionnaire asks about your connection to afterschool centers and your students’ behavior and course grades. If you have any questions about the study or your school’s participation, email us at [STUDY EMAIL]@mathematica-mpr.com.

We would like you to know that:

• The survey will take approximately 10 minutes per student to complete. When you finish, we will send you a $X Visa gift card as a thank-you.

• Your answers will be completely confidential; no information that identifies you, your school, your district, or your student(s) will be reported. Your responses are protected from disclosure per the policies and procedures required by the Education Sciences Reform Act of 2002, Title I, Part E, Section 183. The study team will present the information collected as part of this study in an aggregate form and will not associate responses to any of the people who participate. We will not provide information that identifies you, your school, your district, or your student(s) to anyone outside the study team except if required by law. Your responses will be used only for statistical purposes. The reports prepared for this study will summarize findings across the sample and will not associate responses with a specific district, school, afterschool center, or person. Any willful disclosure of such information for nonstatistical purposes, without the informed consent of the respondent, is a class E felony.

• This survey is voluntary, but your response is critical for producing valid and reliable data. You may skip any questions you do not wish to answer; however, we hope that you answer as many questions as you can. Your answers to questions will not affect your job or any hiring decisions now or in the future and will only be shared with the study team (they will not be shared with anyone from your school or district).

• Participation in the school-day teacher survey does not pose any special risks to you as a respondent. The study has safeguards in place to ensure respondents’ confidentiality, including restricted access to survey data and separating identifying information such as teacher, afterschool center, school, or student names from survey responses. All members of the study team sign a confidentiality pledge, and all staff with access to identifiable study data have received clearance from the U.S. Department of Education and are subject to severe legal consequences for any breach of confidentiality. Any data that identifies you will be destroyed at the end of the study. If you have any questions about your rights as a research volunteer, contact HML IRB toll free at 1-202-753-5040 and reference IRB number XXXXXXXX.

I have read and I understand the above statements and agree to participate in the survey.

If you would like a copy of this disclosure statement, please contact Kristina Rall at [email protected] or
(202) 264-3468.

Paperwork Reduction Act Statement - This information collection meets the requirements of 44 U.S.C. § 3507, as amended by section 2 of the Paperwork Reduction Act of 1995. You do not need to answer these questions unless we display a valid Office of Management and Budget control number. The OMB control number for this information collection is XXXX-0XXX, expiring xx-xxx-20xx. We estimate that it will take about 10 minutes per student to read the instructions, gather the facts, and answer the questions. 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. Send only comments relating to our time estimate to this address, not the completed form.

This document includes 3 parts:

Part 1: This section includes questions about your connection to and coordination with [NAME OF AFTERSCHOOL CENTER].

Part 2: This section includes questions about student behavior and course grades. You will be asked to complete this set of questions for each student listed below. Each student name is included on the label(s) affixed to the start of Part 2.

[NAME OF STUDENT #1] [NAME OF STUDENT #2] [NAME OF STUDENT #3] [NAME OF STUDENT #4] [NAME OF STUDENT #5]

Part 3: This section asks for your contact information in the event we need to conduct any follow-up. It will also be used to send you the $X Visa gift card as a thank you.

PART 1. Your Connection to and Coordination with the Afterschool Center

The following questions ask about your interactions with and knowledge of [NAME OF AFTERSCHOOL CENTER]’s efforts to improve staff practices.

1a. During the [2021-2022 or 2022-2023] school year, did you work in the afterschool center? Please check yes even if you only worked in the center for part of the year.

1  Yes

0  No

1b. During the [2021-2022 or 2022-2023] school year, as part of your work as a school-day teacher, how often did you typically coordinate with the afterschool center?

Examples of coordinating include, but are not limited, to sharing or receiving information about students’ progress and challenges, sharing information about school-day curricula, receiving information or providing input on afterschool curricula, and speaking with afterschool staff to ensure consistency in content or instruction strategies.

MARK ONE ONLY

1  Daily

2  More than once a week

3  A few times per month

4  A few times over the year

5  Never

1c. During the [2021-2022 or 2022-2023] school year, how familiar were you with the training or support that the afterschool center received to improve the quality of its program?

MARK ONE ONLY

1  Very familiar

2  Somewhat familiar

3  A little familiar

4  Not at all familiar

PART 2. Student Behavior and Course Grades

[AFFIX BARCODE AND STUDENT NAME LABEL HERE]

The following question asks about the school-day behavior of the student listed on the label above.

2a. Thinking about the student’s behavior at school during the past month, how often did the student…

If you did not see this student in a situation listed below, take your best guess about how the student would behave in that situation at school.

SSIS Social and Emotional Learning Brief Scales (SSIS SELb; Elliott et al., 2020; 20 items)

This question will have 20 additional items. These items will consist of all 20 items in the SSIS SELb—Teacher K-12 assessment. The items will ask school-day teachers to report behaviors of their student that reflect the student’s social and emotional skills. For each item, they will select how often the student displays each behavior (never, seldom, often, or almost always). The SSIS SELb is proprietary.

	NEVER	SELDOM	OFTEN	ALMOST ALWAYS
a. REDACTED	1 □	2 □	3 □	4 □
b. REDACTED	1 □	2 □	3 □	4 □
c. REDACTED	1 □	2 □	3 □	4 □
d. REDACTED	1 □	2 □	3 □	4 □
e. REDACTED	1 □	2 □	3 □	4 □
f. Keep working towards an important goal even when there was a problem ............................................................................................	1 □	2 □	3 □	4 □
g. REDACTED	1 □	2 □	3 □	4 □
h. REDACTED	1 □	2 □	3 □	4 □
i. REDACTED	1 □	2 □	3 □	4 □
j. REDACTED	1 □	2 □	3 □	4 □
k. REDACTED	1 □	2 □	3 □	4 □
l. Stay focused on the same goal ........................................................	1 □	2 □	3 □	4 □
m. REDACTED	1 □	2 □	3 □	4 □
n. REDACTED	1 □	2 □	3 □	4 □
o. REDACTED	1 □	2 □	3 □	4 □
p. REDACTED	1 □	2 □	3 □	4 □
q. REDACTED	1 □	2 □	3 □	4 □

2a. (cont.) Thinking about the student’s behavior at school during the past month, how often did the student…

If you did not see this student in a situation listed below, take your best guess about how the student would behave in that situation at school.

	NEVER	SELDOM	OFTEN	ALMOST ALWAYS
r. Stay focused on a project that matters a lot to them even when there were a lot of distractions	1 □	2 □	3 □	4 □
s. REDACTED	1 □	2 □	3 □	4 □
t. REDACTED	1 □	2 □	3 □	4 □
u. REDACTED	1 □	2 □	3 □	4 □
v. REDACTED	1 □	2 □	3 □	4 □
w. REDACTED	1 □	2 □	3 □	4 □
x. Try again when they failed to reach an important goal	1 □	2 □	3 □	4 □

The following questions ask for grades in the [2021-2022 or 2022-2023] school year for the student listed on the label above.

2b. Do you teach this student English language arts?

1  Yes

0  No GO TO 2d

2c. For the [2021–2022 or 2022-2023] school year, what grade has the student earned so far in English language arts?

MARK ONE ONLY

1  A+	10  D+
2  A	11  D
3  A-	12  D -
4  B+	13  F
5  B	14  No grade given
6  B-	15  Other (specify)
7  C+
8  C
9  C -

2d. Do you teach this student math?

1  Yes

0  No GO TO PART 3

2e. For the [2021–2022 or 2022-2023] school year, what grade has the student earned so far in math?

MARK ONE ONLY

1  A+	10  D+
2  A	11  D
3  A-	12  D -
4  B+	13  F
5  B	14  No grade given
6  B-	15  Other (specify)
7  C+
8  C
9  C -

Part 3. CONTACT INFORMATION

3a. Who is the person that completed most of this questionnaire?

Please note, this information will not be shared or published in any reports. We ask for this information in the event we need to verify the information provided in the survey. We will also use this information to send you a $X Visa gift card to thank you for participating.

Name:

Address:

City, State, Zip Code:

Date: | | | / | | | / | | | | |

Month Day Year

Phone Number: | | | | - | | | | - | | | | |

Area Code Number

Thank you for taking the time to complete this survey.