Active and Passive Parent Permission Form

APPENDIX E
ACTIVE AND PASSIVE PARENT PERMISSION FORMS

OMB Number:
Expiration Date:

P.O. Box 2393
Princeton, NJ 08543-2393
Phone: 609-799-3535
Fax: 609-799-0005

Month 2018
Dear Parent or Guardian,
Your child’s school is participating in a national study sponsored by the U.S. Department of Education that will
examine the effects of elementary schools using “Departmentalized Instruction”. The goal of the study is to
determine whether students learn more if they are taught by one teacher who focuses just on teaching math and
another teacher who focuses on teaching reading (departmentalized instruction), or if they are taught by a single
teacher who teaches both math and reading. To understand how these two approaches may affect students’ learning,
teachers need to be recorded in their classrooms while teaching math or reading.
The U.S. Department of Education selected Mathematica Policy Research to lead this study. Mathematica is a
research firm that conducts studies for federal and state governments, foundations, and the private sector. For more
information about Mathematica, please visit www.mathematica-mpr.com.
Your child’s classroom will be video recorded this spring. The number of recordings per classroom will vary
slightly, but typically a class will be recorded twice. A trained study team member will conduct the video
recordings. They will make every effort to avoid disrupting the class and only about 30 minutes of instruction will
be recorded on each visit.
Please know that:
 Your child’s identity, as well as that of other students, teachers, and schools, will be kept confidential (per
the policies and procedures required by the Education Sciences Reform Act of 2002, Title I, Part E, Section
183).
 Video recordings will be used only to examine teacher instruction. Interactions between the teacher and
some students may be captured in the recordings, but they will not be used to examine any student’s behavior
or academic performance.
 Video recordings will be viewed only by the study team.
 Video recordings will be destroyed at the end of the study.
Allowing your child to be included in these recordings is voluntary; refusing permission will not affect your child’s
grade. If you allow your child to be included in the recordings, you or your child can choose to stop participating at
any time. If you do not allow your child to be included, we will ask the teacher to seat your child outside the range
of the camera while the classroom is being recorded.
Please let us know whether you allow your child to be included in the recordings by completing the attached
pink form. If you give your permission for your child to be included in the recordings, please check “yes” on the
form; if you do not give permission, check “no.” Then fill out the information at the bottom of the form, sign it, and
have your child return it to his or her teacher within one week. Please keep this letter for your records. If you have
questions about this study or your child’s participation, please contact the study team toll-free between 9 a.m. and 9
p.m. Eastern Standard Time at [x-xxx-xxxx] or email us at [study email address] Monday through Saturday. Or, you
can call or email Bryce Onaran, Mathematica’s Deputy Survey Director, at 202-484-4524 or
bonaran@mathematica-mpr.com.
Sincerely,

Alison Wellington, Ph.D.
Project Director
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 10 minutes, including the time to review and complete the parent permission
form. 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.

Approved by NEIRB on: [Date]

Impact Evaluation of Departmentalized Instruction in
Elementary Schools
CLASSROOM VIDEO RECORDING—PARENT PERMISSION FORM
[Month, Year]

Please complete this form and have your child return it to his/her teacher within one week.
I have read the attached information sheet describing the study. By signing this form, I am
saying:
YES, I give my permission for my son/daughter to be included in video recordings
of his or her teacher’s 4th or 5th grade class by Mathematica Policy Research.
OR
NO, I do not give permission for my son/daughter to be included in video recordings
of his or her teacher’s 4th or 5th grade class by Mathematica Policy Research. I
request that my child be seated outside the range of the camera while the class is
being video recorded.

YOUR CHILD’S NAME

YOUR CHILD’S TEACHER’S NAME

PARENT OR GUARDIAN SIGNATURE

DATE

PARENT OR GUARDIAN NAME (PLEASE PRINT NAME)

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 [xxxxx-xxxx]. The time required to
complete this information collection is estimated to average 10 minutes, including the time to review and complete the parent permission
form. 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.

Approved by NEIRB [Date]

OMB Number:
Expiration Date:

Student’s Assent for the Study of Math and Reading Instruction
What is the study about?
The study will help your school district learn more about how to help
teachers improve their teaching.
Why are you video recording my classroom?
We will record your teacher’s classroom to better understand their teaching.
Who will see the recordings?
Only the people who are doing the study will see the recordings. When the
study is over, all recordings will be destroyed.
What if I am okay being included in the video recordings of my
teacher’s classroom?
If you are okay being included in the video recordings, mark “YES” below.
What if I do not want to be included in the video recordings?
You do not have to be recorded if you do not want to be. If you do not want
to be included, mark “NO” below. Your teacher will seat you where the
camera cannot see you.
If you first decide to be in the recording, but then change your mind, you can
stop being included in the recording by telling your teacher.
Now that I know about the video recording, here is what I decided:
 YES, I will be included in the video recordings of my teacher’s

classroom
 NO, I do not want to be included in the video recordings of my
teacher’s classroom
Your name (printing is OK)

Date

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 [xxxxx-xxxx].
The time required to complete this information collection is estimated to average 10 minutes, including the time to review and
complete the parent permission form. 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.

NEIRB Approval on [Date}

OMB Number:
Expiration Date:

P.O. Box 2393
Princeton, NJ 08543-2393
Phone: 609-799-3535
Fax: 609-799-0005

Month 2018
Dear Parent or Guardian,
Your child’s school is participating in a national study sponsored by the U.S. Department of Education that will
examine the effects of elementary schools using “Departmentalized Instruction”. The goal of the study is to determine
whether students learn more if they are taught by one teacher who focuses just on teaching math and another teacher
who focuses on teaching reading (departmentalized instruction), or if they are taught by a single teacher who teaches
both math and reading. To understand how these two approaches may affect students’ learning, teachers need to be
recorded in their classrooms while teaching math or reading.
The U.S. Department of Education selected Mathematica Policy Research to lead this study. Mathematica is a
nonpartisan research firm that designs studies, collects data, and conducts analysis for the federal and state
governments, foundations, and the private sector. For more information about Mathematica, please visit our website at
www.mathematica-mpr.com.
Your child’s classroom will be video recorded this spring. The number of recordings per classroom will vary slightly,
but typically a class will be recorded twice. A trained study team member will conduct the video recordings. They will
make every effort to avoid disrupting the class and only about 30 minutes of instruction will be recorded on each visit.
Please know that:
 Your child’s identity, as well as that of other students, teachers, and schools, will be kept confidential (per the
policies and procedures required by the Education Sciences Reform Act of 2002, Title I, Part E, Section 183).
 Video recordings will be used only to examine teacher instruction. Interactions between the teacher and some
students may be captured in the recordings, but they will not be used to examine any student’s behavior or
academic performance.
 Video recordings will be viewed only by the study team.
 Video recordings will be destroyed at the end of the study.
Allowing your child to be included in these recordings is voluntary; refusing permission will not affect your child’s
grade. If you allow your child to be included in the recordings, you or your child can choose to stop participating at any
time. If you do not allow your child to be included, we will ask the teacher to seat your child outside the range of the
camera while the classroom is being recorded.
If you do NOT give permission for your child to be included in the recordings, please complete the attached blue form
and have your child return it to his or her teacher within one week. If you give permission for your child to be
included in the study recordings of his or her teacher’s class, you do not need to return the form (you can just
retain the letter and form for your records).
If you have questions about this study or about your child’s participation, please contact the study team toll-free
between 9 a.m. and 9 p.m. Eastern Standard Time at [x-xxx-xxxx] or email us at [study email address] Monday through
Saturday. Or, you can call or email, Bryce Onaran, Mathematica’s Deputy Survey Director, at 202-484-4524 or
bonaran@mathematica-mpr.com.
Sincerely,
Alison Wellington, Ph.D.
Project Director
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 10 minutes, including the time to and complete the parent permission form. 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.

Approved by NEIRB on: [Date]

Impact Evaluation of Departmentalized Instruction in
Elementary Schools
CLASSROOM VIDEO RECORDING—PARENT PERMISSION FORM
[Month, Year]

Please complete and sign the following form only if you do not give your permission to allow
your child to be included in video recordings of his or her teacher’s classroom. Please have your
child return it to his/her teacher within one week.
I have read the attached information sheet describing the study. By signing this form, I am
saying:
NO, I do not give permission for my son/daughter to be included in video recordings
of his or her teacher’s 4th or 5th grade class by Mathematica Policy Research. I
request that my child be seated outside the range of the camera while the class is
being video recorded.
YOUR CHILD’S NAME

YOUR CHILD’S TEACHER’S NAME

PARENT OR GUARDIAN SIGNATURE

DATE

PARENT OR GUARDIAN NAME (PLEASE PRINT)

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 [xxxxx-xxxx]. The time required to
complete this information collection is estimated to average 10 minutes, including the time to review and complete the parent permission
form. 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.

Approved by NEIRB: [Date]