Consent Form

APPENDIX D
CONSENT FORM FOR ACCESS TO
COLLEGE ENTRANCE
EXAM SCORES

6137-082

Evaluation of the Impact of Teacher Induction Programs
Permission to Collect Data for the Sole Use of the Study
Study Purpose: The Institute of Education Sciences at the U.S. Department of Education has contracted with
Mathematica Policy Research, Inc. to conduct the Evaluation of the Impact of Teacher Induction Programs. The
purpose of the study is to rigorously test whether the nature and extent of teacher induction programs are related to
novice teacher instructional practices and retention. Through various modes of data collection—both quantitative and
qualitative—the study will determine the comparative effectiveness of contrasting methods of teacher induction.
We will conduct a classroom observation as part of your participation in this study. The results of the observation are
kept confidential and will not be shared with anyone outside the Mathematica study team. We will also ask you to
complete brief questionnaires during the course of the study that collect information on your teacher preparation
participation in induction activities and your career path.
Please sign here to indicate your understanding of the study components as stated and your willingness to cooperate
with this data collection effort.
SIGNATURE:

Confidentiality: The information you provide will be held in strict confidence and used only for the study. Your name
will never be used in reporting the results of the study. The confidentiality of your answers is guaranteed by the Privacy
Act of 1974. Under this law, your answers cannot be released in any manner which would enable someone to identify
you unless you give us written consent or as required by law. Providing the information below is voluntary, not
mandatory.
Permission for Releasing SAT/ACT Scores
Please provide us with the following information so that ACT or College Board can locate your records and send them to
Mathematica Policy Research, Inc. only for use by the Impact Evaluation of Teacher Induction Programs Study.
Q1.

At any point in time, did you take the SAT and/or ACT test?
!
!
!

Q2.

Yes, I took the ACT test.
Yes, I took the SAT test.
No, I have never taken either of these tests. (Please complete Q4 only and return this form.)

What was your name at the time the test was taken? (PLEASE PRINT)
_________________________
FIRST NAME

Q3.

Q4.

___________
MIDDLE INITIAL

__________________________________
LAST NAME

Has your name changed since the time you took the test?
!

Yes

!

No

GO TO Q5

What is your current name? (PLEASE PRINT)
______________________________________________________________________
FIRST NAME
MIDDLE INITIAL
LAST NAME

Q5.

What is your Social Security number?
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Q6.

Q7.

What is your gender?
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Female

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Male

What is your date of birth?
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Q8.

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Month
Day

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Year

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What was the name and address of the high school you attended? Please spell out the name of the
state or country.
HIGH SCHOOL NAME:
ADDRESS:

CITY:

STATE:

COUNTRY:

ZIP:

Q9.

In what state or country did you take the test? Please spell out the name of the state or country.
STATE:
COUNTRY:

Q10.

In what year did you take the test?
YEAR: |

Q11.

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Please provide your signature as permission for MPR to obtain your test scores.
SIGNATURE:

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Month
Day

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Year

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If you have any questions regarding this study, please contact the Survey Director, Pat Nemeth at
609-275-2294 or at pnemeth@mathematica-mpr.com.

PLEASE RETURN THIS FORM TO:
Mathematica Policy Research, Inc.
P.O. Box 2393
Princeton, NJ 08543
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 5 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.

P:\Induct.(dp)\OMB (2008)\New Files (2-20-08)\APD-Consent Form (2-19-08).doc
Prepared by Mathematica Policy Research, Inc.

3(REV—4/22/05) 2/21/2008 5:20 PM