Administrator Study Participation Agreement form

Appendix F. REL Midwest CLC Study – Administrator Participation Form

CONTENT LITERACY CONTINUUM

STUDY PARTICIPATION AGREEMENT

DRAFT

Purpose

An evaluation of the Content Literacy Continuum program is being sponsored by the Institute for Education Sciences (IES) in the U.S. Department of Education. The evaluation is being carried out by the Midwest Regional Educational Laboratory (REL Midwest), headed by Learning Point Associates, in collaboration with the research organization MDRC. The purpose of the CLC Study is to study the impact and implementation of a literacy across the curriculum program in high schools.

To assist with the study, we are asking school and district staff to participate in interviews. Depending on your role at the district or school level, you will be interviewed about topics such as class instruction, school and district context, and supports to the intervention programs. The interviews are designed to last about one hour.

The U.S. Department of Education wants to protect the privacy of individuals who participate in surveys. Your answers will be combined with other surveys, and no one will know how you answered the questions. This survey is authorized by law (1) Sections 171(b) and 173 of the Education Sciences Reform Act of 2002, Pub. L. 107-279 (2002); and (2) Section 9601 of the Elementary and Secondary Education Act (ESEA), as amended by the No Child Left Behind (NCLB) Act of 2001 (Pub. L. 107-110).

According to the Paperwork Reduction Act of 1995, no persons are required to respond to a collection of information unless it 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 1 minute per respondent, including the time to review instructions, gather the data needed, and complete and review the information collected. If you have any comments concerning the accuracy of the time estimate(s) 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 status of your individual submission of this form, write directly to: U.S. Department of Education, Institute of Education Sciences, 555 New Jersey Avenue, NW, Washington, DC 20208.

Risks and Discomfort

There are few anticipated or known risks in participating in this study. Data collected and maintained by, or under the auspices of IES, under a pledge of confidentiality shall be treated in a manner that will assure that individually identifiable data will be used only for statistical purposes and will be accessible only to authorized persons.

Benefits

Your participation in the evaluation will contribute to an understanding of how to support the literacy learning and academic achievement of high school students.

Confidentiality

Responses to this data collection 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 or individual. We will not provide information that identifies you or your district to anyone outside the study team, except as required by law.

More Information

If you would like more information about this study, you may contact Matt Dawson, Deputy Director of REL Midwest, at 630-649-6563.

Informed Consent

By signing this form you are indicating that you have read and understood the information provided to you about your participation.

Print Name:_______________________________________________________________________

Signature:________________________________________________ Date:__________________

School/Organization Name:__________________________________________________________

Position at School/Organization:_______________________________________________________________

___________________________________________________________________________________________________________

Learning Point Associates

1120 East Diehl Road, Suite 200

Naperville, IL 60563

Tel. (800) 356-2735