Classroom Roster

APPENDIX I
REQUEST FOR CLASSROOM ROSTER

OMB Control No.: ####-####

Expiration Date: ##/##/####

6522-###

Study of Secondary Math Teachers from Alternative Routes to Certification

Directions to Submit Class Roster for Assignment of Students to a Math Course Section
In order for Mathematica to assign students to classrooms for fall 2009, please do the following:
1. Complete this form (one copy for each math course section that will participate in the study)
2. Fax the completed form back to us toll-free, along with the roster of student names
(fax #: ###-###-####). Please fax to _______________ (school coordinator)
3. When you print out your roster, please include the student’s name and gender. Also, include
the student’s ID, if readily available.
(Examples of a completed form and roster are provided on following pages.)
A. This information and the following roster of students is for:
School
District Name
Math Course
on day/block/family
(please use a new form for every new math course section)

at time(s):

B. Date the class assignment lists should be sent back to the school: _____________________
(Month, day)

C. The attached list of students is to be divided into _____classrooms, with _____ students per class.
(Indicate number)

(Indicate number)

D. Please give the first and last names of the teachers who you expect to teach these math section
classes (write “Unknown” if you have a slot but don’t yet know who the teacher will be):
1.
2.
3.

4.
5.
6.

E. Optional: Indicate one or two criteria (such as academic ability, behavior or gender) that you
would like used in the classroom assignment process. We will make sure the classes are balanced
on these student characteristics. The codes need to be listed next to each student name on your
roster. Please include gender of the student on the rosters. We will automatically balance on
gender if no other criteria has been specified.
Criterion #1

Codes Used

Meaning

Criterion #2

Codes Used

Meaning

F. Optional: Describe any other special considerations or necessary exceptions to assignment lottery
(for example, students who must be assigned to different classes, or students who must be assigned
to a particular teacher). Bear in mind that such requests should not exceed 1 or 2 students per
course section. Please clearly specify, names of the students and their assignment request:
1
2

OMB Control No.: ####-####

Expiration Date: ##/##/####

6522-###

- SAMPLEStudy of Secondary Math Teachers from Alternative Routes to Certification

Directions to Submit Class Roster for Assignment of Students to a Math Course Section
In order for Mathematica to assign students to classrooms for fall 2009, please do the following:
1. Complete this form (one copy for each grade level that will participate in the study)
2. Fax the completed form back to us toll-free, along with the roster of student names
(fax #: 866-898-2004). Please fax to __Nancy Smith_________________ (school coordinator)
3. When you print out your roster, please include the student’s name, ID number, gender, if
readily available.
(Examples of a completed form and roster are provided on following pages.)
A. This information and the following roster of students is for:
School Adams High School
District Name
Jefferson Co.
Math Course Algebra I
on day/block/family
at time(s):
Block A
(please use a new form for every new math course section)

10:00 AM

B. Date the class assignment lists should be sent back to the school: ____June 30___
(Month, day)

C. The attached list of students is to be divided into ___3__classrooms, with _15_ students per class.
(Indicate number)

(Indicate number)

D. Please give the first and last names of the teachers who you expect to teach these math section
classes (write “Unknown” if you have a slot but don’t yet know who the teacher will be):
1.
2.
3.

4.
5.
6.

Maria Zuniga
Delores Hart
Andy Patterson

E. Optional: Indicate one or two criteria (such as academic ability, behavior or gender) that you
would like used in the classroom assignment process. We will make sure the classes are balanced
on these student characteristics. The codes need to be listed next to each student name on your
roster. Please include gender of the student on the rosters. We will automatically balance on
gender if no other criteria has been specified
Criterion #1
Academic Ability

Criterion #2
Gender

Codes Used
H,
M
L
Codes Used
F
M

Meaning
High
Medium
Low
Meaning
Female
Male

F. Optional: Describe any other special considerations or necessary exceptions to assignment lottery
(for example, students who must be assigned to different classes, or students who must be assigned
to a particular teacher). Bear in mind that such requests should not exceed 1 or 2 students per
course section. Please clearly specify, names of the students and their assignment request:
1
2

Bobby Brown and John Jones must be in separate classes
Frances Farmer must be placed in Ms. Zuniga’s class

OMB Control No.: ####-####

Expiration Date: ##/##/####

Adams High School
Algebra I_Block A__10:00 AM_
LAST
Austin
Aybu
Beal
Clapp
Donaldson
Howard
Jones
Murphy
Smith
Avila
Brown
Cervantes
Figures
Fontaine
Galanffy
Garcia
Grant
Hall
Jimenez
Lofy
Mcdonald
Mcfarland
Mcguire
Mcintosh
Petit
Rodriguez
Sauer
Silva
Watson
Wilder
Collins
Difazio
Emery
Farmer
Haston
Hunter
Jacinto
Jonhson
Lopez
Marquez
Maxwell
Murphy
Passarelli
Watson
Weber

FIRST
Allan
Geno
Jordan
Eugenie
Andrew
Kyle
John
Caitlin
Sam
Joshiwe
Bobby
Matthew
Bryant
Marquise
Luis
Gary
Alize
Scott
Nolan
James
Andrea
Gretzel
Zoe
Autumn
Graciela
Morgan
Tiara
Ta Kyia
Alexandra
Tanner
Brandon
Ana
Esmeralda
Frances
Arianna
Madison
Deanna
Dae'ran
Devin
Aaron
Tyler
Ariel
Willis
Lauren
Devin

SAMPLE ROSTER
Jefferson Co.,

ABILITY
H
H
H
H
H
H
H
H
H
L
L
L
L
L
L
L
L
L
L
L
L
L
L
L
L
L
L
L
L
L
M
M
M
M
M
M
M
M
M
M
M
M
M
M
M

GENDER
M
M
M
F
M
M
M
F
M
F
M
M
M
F
M
M
F
M
M
M
F
F
F
F
F
F
F
F
F
M
M
F
F
F
F
F
F
F
M
M
M
F
M
F
F

StudentID
1000351
1000452
1000600
1000601
1000502
1000503
1000901
1000111
1000250
1000605
1000559
1000669
1000999
1000222
1000332
2000352
1000699
1000700
1000801
5000080
9000807
6000991
1000801
1000667
1000553
1000523
2000783
9000900
2000352
3000651
1000485
1000145
1000267
1000167
1000876
1000356
1000984
1000691
9000678
9000177
9000168
9000134
1000143
1000144
1000145

6522-###