Parent Consent Forms

Attachment 1

Parental Consent Form

The Upward Bound Research Study

The U. S. Department of Education is studying the Upward Bound program to learn how the program helps students succeed in high school and prepare for college. Three research companies—Abt Associates, the Urban Institute, and Berkeley Policy Associates—were hired to do this study. The study will include more than 3,500 students across the country.

Right now more students want to be in Upward Bound than there are spaces available. So, students will be chosen by lottery to get into this Upward Bound project this year. The U. S. Department of Education is asking permission for students entering the lottery to fill out a brief survey. Students who go through the lottery and do not get into Upward Bound can still be part of this study. These students may still participate in other programs or services. We will ask students in the study to fill out another survey two years from now. We are also asking your permission to collect some school, College Board, and ACT records on your child. This information will be used only for research purposes. In particular, we will use this information to compare outcomes for groups of students in Upward Bound with outcomes for groups of students in other programs.

What it Means to Participate

Your child is not required to participate in this study in order to enter the lottery to be admitted to Upward Bound. However, before the lottery can occur, we need you to indicate whether or not you give permission for your child to participate in the study. You indicate your decision by checking one of the boxes below, printing your child’s name, and printing and signing your own name. If you give permission, we ask your child to read and sign an assent form and complete a survey and return them to us with this form in the envelope provided. If you don’t give permission, we ask you to return this form to us indicating your decision. Then, the study staff will put your child’s name in the lottery with other applicants. This lottery picks who will get into the project and who will not. If your child enters the lottery and is not picked to get into Upward Bound, he or she cannot enter an Upward Bound project at another time, but can still try to get into other programs or services. Whether your child is in the study or not, he or she still has to go through the same lottery to get into this Upward Bound project this year. We really would like to have your child be in the research study.

We would like as many students as possible to participate in this study because it will help identify ways to improve Upward Bound and similar programs. However, your child’s participation is voluntary. Whether your child is part of the study won’t affect whether he or she is eligible for any program or service. If you give permission and your child also agrees to be in the study, your child will be asked to fill out two brief surveys, one before the lottery takes place, and another in about two years. While completing the survey is important, there might be some survey questions your child does not want to answer. Your child does not have to answer any question he or she does not want to. Also, the study will ask for some of your child’s school, College Board, and ACT records in about two years and before your child turns 18 years old. The records we plan to use for the study are school attendance, courses taken, grades, and results of any state reading and math tests and PSAT, SAT, AP, and ACT tests. When your child is 18, we will ask for your child’s permission for any additional data collection if needed. We are asking permission for your child’s Social Security Number, so that we may more easily obtain your child’s school, College Board, and ACT records.

Privacy

Protecting your child’s privacy is very important to us. The U. S. Department of Education and the companies doing the study will follow strict rules to protect your child’s privacy. Your child’s name, and the name of your child’s school, will not appear in any reports produced for this study. These reports will only present information for groups, not for individual children. Your child’s answers and records will be kept private from Upward Bound and school staff, employers, friends, and family. Your child’s name and Social Security Number will be replaced with a different I.D. number for the purpose of this study. Any information on your child entered into a database will be stored on a secure computer network. Paper copies of your child’s survey responses will also be stored securely. We will not provide information that identifies your child or your child’s school to anyone outside the study team, except as required by law.

There are strong penalties for anyone who uses this study to share information on your child without permission: up to a $250,000 fine and five years in prison. There is, however, a very small chance that someone will see your child’s survey answers or school, College Board, or ACT records without permission. The U.S. Department of Education has established procedures to investigate any potential disclosure and will take vigorous action to prosecute any wrong-doing.

Questions About the Study

If you have any questions about the survey, please call 1-800-____-______ (toll free). If you have questions about the study, please call Dr. Alan Werner, Study Director, at 617-349-2832 (toll call). Questions about your rights, please call Ms. Marianne Beauregard, at 617-349-2852 (toll call).

1. Please read the following statement. The Upward Bound project to which your child is applying is participating in a national study. This U.S. Department of Education study is being conducted by Abt Associates, the Urban Institute, and Berkeley Policy Associates under a contract with the Department. The purpose of the study is to learn how Upward Bound helps students succeed in high school and prepare for college. The study is permitted under Section 402H of the Higher Education Act of 1965, 20 U. S. C. 1070a-18. We would like your child to participate in this important study. For your child to participate, we ask your permission to collect survey information from your child both now and two years from now. We also ask permission for the three research companies above to use your child’s name and Social Security Number to obtain school, College Board, and ACT records on your child. In accordance with the Privacy Act (5 U.S.C. Section 552a) and the Institute of Education Sciences confidentiality statute (20 U.S.C. 9573, Section 183), the information gathered on your child will be kept strictly confidential and will be used by the Department and its contractors ONLY for the purpose of the study, except if required by law. 2. After reading the above statement, do you give permission for your child to participate in the National Evaluation of Upward Bound (including the collection of survey information and the obtaining of student records as described above)?
	YES, my child _____________________________________________________________________
	First Name Last Name has my permission to participate in the National Evaluation of Upward Bound.
	Child’s Social Security Number: _____ - _____ - ______
	NO, my child _____________________________________________________________________
	First Name Last Name does NOT have my permission to participate in the National Evaluation of Upward Bound.
Print Your Name: First Name Last Name
Signature: Date:
Your Telephone Number: ( ) ____________ - _____________________ Area Code

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 will be entered after clearance. The time required to complete this information collection is estimated to average 15 minutes per response, including the time to review instructions, search existing data resources, gather the data needed, and complete and review the information collection.

Abt Associates Inc. Parental Consent Form 1