Impact Study of Feedback for Teachers Based on Classroom Videos

APPENDIX D
STUDENT ENUMERATION AND DATA REQUEST FORM

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STUDENT ENUMERATION DATA REQUEST
Impact Study of Feedback for Teachers
Based on Classroom Videos
Conducted on behalf of the United States Department of Education
As part of the study, we need to collect lists of all students enrolled in classes taught by the
teachers participating in this study, some of whom teach at [School Name]. These lists will be
used to prepare parent information and permission packets that we will ask teachers to
distribute to their students. The participating teachers at this school are:
[Teacher 1 First Name] [Teacher 1 Last Name]
[Teacher 2 First Name] [Teacher 2 Last Name]
[Teacher 3 First Name] [Teacher 3 Last Name]
The class lists should reflect information as of [MONTH DAY YEAR], and include all students
enrolled in classes taught by the teachers listed above. Please provide separate class
lists for each distinct class or section taught by each teacher.
For each student included in a class list, please provide his or her student ID number, first
name, last name, and grade level. You may generate your own lists containing this
information or use the Student Enumeration Forms that accompanied this data request. If
generating your own lists, please provide the files in .xls, .csv, or .txt format. Please do not
submit completed forms via email.
You can submit forms either by (1) returning the completed forms to the Mathematica field
representative that will be visiting your school on [DATE] or (2) uploading the data file to our
secure file transfer website by [DATE]:
[link]
Your username is: [XXXX]
Password: Please call [XXXXXX] at [PHONE] (or the study team at [TOLL-FREE PHONE]) for
the website password.
This is a secure site that will protect the privacy of the requested data. If you have any questions
about completing this data request, please contact [XXXXXX] at [PHONE], or a member of the
study team toll-free at [TOLL-FREE PHONE] or [EMAIL].
Thank you for your time!

***Please DO NOT email the student list file***
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 xxxx-xxxx. The time required to
complete this information collection is estimated to average 60 minutes, including the time to review instructions, search existing data
sources, gather the data needed, and complete and review the information collection. If you have any comments concerning the accuracy
of the time estimate 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 content or the status of your individual submission of this form, write directly to: U.S. Department
of Education, Institute of Education Sciences, 550 12th Street, SW, Washington, DC 20202.

OMB Approval No.: XXXX-XXXX
Expiration Date: XX/XX/20XX

STUDENT ENUMERATION FORMS
Impact Study of Feedback for Teachers
Based on Classroom Videos
Conducted on behalf of the United States Department of Education

Instructions
Please use these forms to provide a list of all students enrolled in any classes taught by
[Teacher First Name] [Teacher Last Name] at [School Name]. For each student in a class,
please provide student ID number, first name, last name, and grade level in the fields provided.
If [Teacher First Name] [Teacher Last Name] teaches more than one class or section of
students, please complete one form for each class or section taught.
These lists will be used to prepare parent information and permission packets, which will inform
parents that some of [Teacher First Name] [Teacher Last Name]’s classes may be video
recorded for instructional and research purposes during the school year. Parents will be asked
to give permission for their children to appear in classroom videos. Parent information packets
will be distributed by teachers and will contain information about the study. The packets will
contain a toll-free number for additional information about the study and about Mathematica
Policy Research, who is conducting this study for the U.S. Department of Education.
If you prefer, you can generate your own list containing the class subject/period, students’ first
and last name, student ID, and grade level for all students enrolled in [Teacher First Name],
[Teacher Last Name]’s classes – one list per class.
A Mathematica field representative will collect this form or you can upload it to our secure file
transfer website provided in the data request accompanying this form.

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 xxxx-xxxx. The time required to
complete this information collection is estimated to average 60 minutes, including the time to review instructions, search existing data
sources, gather the data needed, and complete and review the information collection. If you have any comments concerning the accuracy
of the time estimate 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 content or the status of your individual submission of this form, write directly to: U.S. Department
of Education, Institute of Education Sciences, 550 12th Street, SW, Washington, DC 20202.

[School Name]

{School NCES ID: XXXXXXXX}

[Teacher First Name] [Teacher Last Name]

Teacher’s District ID: ________________________

Teacher MPRID: XXXXXXXX
Name/Period of Class: __________________________

Total Number of Students in Class: ____________

Does this teacher teach this same group of students for all academic subjects? ☐ Yes

☐ No

(If yes, please write in “All Subjects” in the “Subject” field below, complete this page, then skip to the end of the
document. If no, please complete a form for each class or section taught by this teacher.)
Subject ____________________________________________________________________________________
STUDENT ID
NUMBER

STUDENT FIRST NAME

STUDENT LAST NAME

STUDENT
GRADE LEVEL

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[School Name]

{School NCES ID: XXXXXXXX}

[Teacher First Name] [Teacher Last Name]

Teacher’s District ID: ________________________

Teacher MPRID: XXXXXXXX
Name/Period of Class: __________________________

Total Number of Students in Class: ____________

Does this teacher teach this same group of students for all academic subjects? ☐ Yes

☐ No

(If yes, please write in “All Subjects” in the “Subject” field below, complete this page, then skip to the end of the
document. If no, please complete a form for each class or section taught by this teacher.)
Subject ____________________________________________________________________________________
STUDENT ID
NUMBER

STUDENT FIRST NAME

STUDENT LAST NAME

STUDENT
GRADE LEVEL

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[School Name]

{School NCES ID: XXXXXXXX}

[Teacher First Name] [Teacher Last Name]

Teacher’s District ID: ________________________

Teacher MPRID: XXXXXXXX
Name/Period of Class: __________________________

Total Number of Students in Class: ____________

Does this teacher teach this same group of students for all academic subjects? ☐ Yes

☐ No

(If yes, please write in “All Subjects” in the “Subject” field below, complete this page, then skip to the end of the
document. If no, please complete a form for each class or section taught by this teacher.)
Subject ____________________________________________________________________________________
STUDENT ID
NUMBER

STUDENT FIRST NAME

STUDENT LAST NAME

STUDENT
GRADE LEVEL

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[School Name]

{School NCES ID: XXXXXXXX}

[Teacher First Name] [Teacher Last Name]

Teacher’s District ID: ________________________

Teacher MPRID: XXXXXXXX
Name/Period of Class: __________________________

Total Number of Students in Class: ____________

Does this teacher teach this same group of students for all academic subjects? ☐ Yes

☐ No

(If yes, please write in “All Subjects” in the “Subject” field below, complete this page, then skip to the end of the
document. If no, please complete a form for each class or section taught by this teacher.)
Subject ____________________________________________________________________________________
STUDENT ID
NUMBER

STUDENT FIRST NAME

STUDENT LAST NAME

STUDENT
GRADE LEVEL

1.
2.
3.
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