Parental Consent Form

Attachment L
Parental Consent Form

Dear Parent,
Our school is taking part in a study of violence prevention programs in middle schools. The study is sponsored
by the U.S. Department of Education and will be conducted by RTI International, a research firm in North
Carolina. This consent form asks your permission for RTI International to do the following:
‚

Administer a survey to your child this year and in school years 2007-08 and 2008-09. Questions ask about
school rules, attitudes about violence, feelings of safety and getting along with others. Other questions ask
about violent or criminal behaviors. The survey also asks about your child’s race, gender, birth date, and
which family members the student lives with (but not their names). The survey will be given to your child in
school and will take no more than one class period. Students will be told that the survey is voluntary.
Students will also be told they can choose to skip any questions.

‚

Collect limited information from your child’s school records on attendance, school policy violations, and
disciplinary actions such as detention, suspensions, and expulsions. If your child does not take the survey,
RTI will not collect information from your child’s school records.

Any information collected about your child will be treated confidentially. The information that is identified with
your child will be used only by RTI International for the study and will not be used for any other purpose.
Parents, school personnel, family members, and other students will not have access to this information. Your
name and your family’s name will not be used in any reports about the program.
There is no compensation for your child’s participation. Completing this survey will pose little risk to your child.
There is a chance that your child may want to talk with someone after taking the survey. Students will get
information about school staff they can talk to and a list of Hotline numbers they can call.
If your child moves to another middle school in the district after this year, a survey may be given to your child at
the new school. It is important that your child be surveyed each year. However, parents may withdraw their
consent at any time by contacting the school principal. No action will be taken against the school, you, or your
child, if your child does not participate in the survey. Parents may review the survey in the Principal's office
before the survey is administered and before signing this consent form. The survey will be available for review
each year.
If you have any questions or concerns about your child's rights as a participant in the study, you may call RTI's
Office of Research Protection at 1-866-214-2043 (a toll-free number). If you have questions about the survey,
please contact the project director, Dr. Suyapa Silvia, at RTI—1-800-334-8571, extension 5851.
Please read the information below and check one box. A parent must sign and return this consent form no later
than [DATE] so that your child may participate in this survey.

[PLEASE PRINT] Child's name: _____________________________________ Grade: __________
I have read this form and understand it.
[

]

[

]

I GIVE PERMISSION for my child to take part in this survey and for my child’s school records to be
reviewed this school year and in 2007-08 and 2008-09.
I DO NOT GIVE PERMISSION for my child to take part in this survey or for my child’s records to be
reviewed.

[PLEASE PRINT]

Parent's name: _________________________________

Date: ___________

Parent's signature: ______________________________

Date: ___________

Phone number: ________________________________