School/Teacher Contact Information

School/Teacher Contact Information

Teacher Contact Information

Thank you, in advance, for responding to the following questions. This instrument is being administered as part of a long-term research project by WestEd to examine the impact of the Lessons in Character Program (LIC) — an English language arts-based character education program — on student academic performance, attendance, school motivation, and endorsement of universal values consistent with character education. WestEd, a research, development, and service agency, works with education and other communities to promote excellence, achieve equity, and improve learning for children, youth, and adults.

This form is designed to collect contact information for a school-site contact and teachers who will be participating in the study. According to the Paperwork Reduction Act of 1995, no persons are required to respond to a collection of information unless such collection displays a valid OMB control number. The valid OMB control number for this information collection is 1850-0826. The time required to complete this information collection is estimated to average 30 minutes per response, including the time to review instructions, search existing data resources, gather the data needed, and complete and review the information collection.  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, D.C. 20202-4651.  If you have comments or concerns regarding the status of your individual submission of this form, write directly to: Rafael Valdivieso, U.S. Department of Education, 555 New Jersey Avenue, NW, Room 506E, Washington, D.C. 20208.

This collection of information is authorized by Public Law 107-279 Education Sciences Reform Act of 2002, Title I, Part C, Sec. 151(b) and Sec. 153(a). Participation is voluntary. Your responses are protected from disclosure by federal statute (PL 107-279 Title I, Part C. Sec. 183). All responses that relate to or describe identifiable characteristics of individuals may be used only for statistical purposes and may not be disclosed, or used, in identifiable form for any other purpose, unless otherwise compelled by law. Data will be combined to produce statistical reports. No individual data that links your name, address, telephone number, or identification number with your responses will be included in the statistical reports.

Please contact Dr. Barbara Dietsch with any questions at 562.799.5126 or by email at bdietsc@wested.org.

ADCD Elementary School

ABCD School District

123 Main Street

ABCD, CA 99999

Barbara Dietsch, PhD

Project Director

WestEd

4665 Lampson Avenue

Los Alamitos, California 90720

Fax: (562) 799-5151

Dear Dr. Dietsch:

This is to confirm that our school will participate in the Lessons in Character research project beginning in Spring 2007 and ending Spring 2009. We have at least 3 teachers per grade level (grades 1-5) who are eligible to participate.

Please contact the following person to coordinate the teacher selection, training, and data collection activities.

Contact person: ______________________________

Title: _______________________________________

Phone number: _______________________________

Fax number: __________________________________

E-Mail Address: ______________________________

Sincerely,

__________________________________ Date______________

Mr. Jones

Principal

Please complete this form with the names of teachers who will be implementing the Lessons in Character program this year, the grade level they teach and the best way to contact them. You may contact Dr. Barbara Dietsch with any questions, at 562.799.5126 or by email at bdietsc@wested.org.

Teacher Name		Teacher ID	Grade Level	Room Number	Email address	Phone Number	Cell Phone
Last	First