Parent Consent Form and Survey

OMB Control No. xxxx-xxxx

Approval expires xx/xx/xxxx

Appendix 1: Parent Consent Form and Survey (Paper)

N ational Evaluation of NASA’s Summer of Innovation

NASA’s Office of Education has a national program called Summer of Innovation. This program is for middle school students. Two research companies—Abt Associates and the Education Development Center—are evaluating the program for NASA.

NASA would like student feedback for this evaluation. The evaluation will help us improve the Summer of Innovation program. However, your child’s participation in the evaluation is voluntary. Your child can take part in the program even if he/she does not take part in the evaluation.

What it Means For Students to Take Part in the Voluntary Evaluation

• Some students will be asked to complete 3 short surveys: one survey at the start and end of the summer program and one survey by mail in spring 2013.

• These surveys include questions about interest in science and about taking part in science activities.

• The evaluation will include more than 20,000 students.

• Your child does not have to answer any question he or she does not want to.

• All information will be used only for evaluating the program.

Securing Your Child’s Responses

Protecting your child’s privacy is very important to us.

• NASA Office of Education, the companies doing the study, the awardees’ local evaluators and the program’s staff will follow strict rules to protect your child’s privacy.

• The study reports will not include your child’s name, the name of your child’s school, or the name of your child’s Summer of Innovation program.

• We will not share information that identifies your child to anyone outside the study team, the evaluators of the local programs, and the Summer of Innovation staff.

• There is a very small chance that someone will see your child’s name and survey answers without permission. We have many steps in place to protect the privacy of your child, so we do not think this will happen.

Questions About the Evaluation

For questions about the evaluation, please email NASASummerofInnovation@abtassoc.com or call Hilary Rhodes, Study Director, at 877-520-6840 (toll-free). For questions about your child’s rights as a participant in this evaluation, please call Abt’s Institutional Review Board Administrator, Teresa Doksum at 877-520-6835 (toll-free).

Paperwork Reduction Act Statement - This information collection meets the requirements of 44 U.S.C. § 3507, as amended by section 2 of the Paperwork Reduction Act of 1995. You do not need to answer these questions unless we display a valid Office of Management and Budget control number. We estimate that it will take about 10 minutes to read the instructions, gather the facts, and answer the questions. You can find additional information on this program at http://www.nasa.gov/offices/education/programs/national/summer/home/index.html. You may send comments on our time estimate above to: NASASummerofInnovation@abtassoc.com. Please send only comments relating to our time estimate to this address, not the completed form. For questions about this evaluation, please contact the evaluation director, Hilary Rhodes of Abt Associates Inc. at (877) 520-6840 (toll-free) or send an email to NASASummerofInnovation@abtassoc.com. For more information about this data collection, including OMB clearance and burden estimates, please contact Lori Parker, NASA PRA Clearance Officer (lori.parker@nasa.gov, 202-358-4616—not a toll-free number). For questions about your rights as a participant in this study, contact Teresa Doksum at the Abt Associates Inc. Institutional Review Board (877-520-6835- toll-free).

1. 2. Do you give permission for your child to take part in the National Evaluation of N NASA’s Summer of Innovation?
	YES, my child _____________________________________________________________________
	First Name Last Name has my permission to take part in the national evaluation of NASA’s Summer of Innovation.
	NO, my child ______________________________________________________________________
	First Name Last Name Does not have my permission to take part in the national evaluation of NASA’s Summer of Innovation.
Print Your Name: ______________________________________________________________________ First Name Last Name
Signature: Date: ________________________
Telephone no.: ( ) ________________			Alternate telephone no.: ( ) _______________________
Permanent email address (optional): ________________________________________________________
Alternative email address (optional): ________________________________________________________
Student mailing street address:_____________________________________________________________
City:______________________________			State: ________________		Zip code: _________________
Emergency Contact (other than parent) First Name:_______________________		Last Name: ________________________________________
Relationship to student: _________________________________________________________________
Telephone no.: ( ) ________________________				Best time to call:__________________________
Alternative telephone no.: ( ) _________________________________________________________

Please turn the page.

We have a few questions that we would like to get about you and your child for the study.

1. Child’s First and Last Name:

2. What is your child’s birthday? Month: ________ Day:_______________

3. What school will your child attend in fall 2011? _______________________

4. What grade level will your child enter in fall 2011?

4^th 5^th 6^th 7^th 8^th 9^th Other: ____________________

5. What is your child’s gender?

Male Female

6. What is your child’s ethnicity? Please check one only.

 Hispanic or Latino

 Not Hispanic or Latino

7. What is your child’s race? Please check one or more.

American Indian or Alaska Native

Asian

Black or African American

Native Hawaiian or Other Pacific Islander

White

8. At any point during the previous school year, did your child receive free or reduced price lunch from the National School Lunch Program?

Yes No Don’t know

9. As things stand now, how far in school do you think your child will get?

• Less than high school

 High school diploma or GED

 Start but not complete college

 Complete college

 Start but not complete courses after graduating from college

 Complete an advanced degree after graduating from college

• I don’t know

10. What is the highest level of education you have completed?

 Less than high school (Skip to Question 12)

 High school diploma or GED (Skip to Question 12)

 Associate’s degree

 Bachelor’s degree

 Master’s degree

 Educational Specialist diploma

 Ph.D., M.D., law degree, or other high level professional degree

11. Did you major in a science, technology, engineering, or mathematics field in college or beyond?  

Yes No Don’t know

12. Do you work in a science-related occupation?

Yes No Don’t know

13. Why is your child attending this program? Please check one or more.

Student needs summer supervision

 Student is interested because friends are attending

 Student is interested because of career goals

 Student is interested because of the science enrichment activities offered

 Parent is interested in science enrichment programs

 Teacher recommended program

 Student needs assistance in science

 Student is interested because of future classes

 Additional reasons for attending the program: __________________________________

Abt Associates Inc. Appendix 1 1-5