Formative Assessment Study/Study Participation Agreement

Appendix D. REL Midwest Formative Assessment Study – Student Participation Form

FORMATIVE ASSESSMENT STUDY

STUDY PARTICIPATION AGREEMENT

DRAFT

Your son/daughter’s school is participating in a study of a program that provides professional development to teachers related to formative assessment and differentiated instruction.

The goal of this national study is to learn whether using data from formative assessments can improve students’ reading and math achievement. Only those students at whose parents agree to let them be part of the study will have a chance to participate in this study.

To be part of the study, parents and students must understand the following:

• For students participating in the study, the study will only collect information from school records. This will include information such as students’ attendance, free/reduced-price lunch status, and test scores.

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

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 90 minutes 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.

Please indicate YES or NO with an X in the box below.
[ ] YES, I give permission for my child to participate in this study.	[ ] NO, I do not give permission for my child to participate in this study.

Print Name of Parent/Guardian: ___________________________________________________

Parent/Guardian Signature: _______________________________________________________

Phone Number: (______) _____________________ Date: _____________________________

Print Name of Student: _________________________________________________________

Student Signature: _____________________________________________________________

Student Birthdate: _____/_____/_________ Student ID Number: ________________________