School Agreement Form

APPENDIX F
SCHOOL AGREEMENT FORM

OMB Number:
Expiration Date:

Evaluation of Departmentalized Instruction in Elementary Schools
School Agreement Form
On behalf of the 4th and 5th grade teachers in my school, as the principal or principal’s designee, I volunteer my
school to participate in this study.
• I certify that our school currently does not use departmentalized instruction for math or reading (English
language arts) in 4th or 5th grade. Likewise, if any 4th or 5th grade teachers at my school co-teach, I certify that
they do not primarily teach just one of those two subjects.
• I acknowledge that if chosen for the study, my school will be selected by lottery to either one of two groups:
the departmentalized instruction or self-contained instruction group.
o If selected for the departmentalized instruction group, I agree to departmentalize math and reading
instruction in 4th and 5th grades in both the 2018–2019 and 2019–2020 school years.
o If selected for the self-contained instruction group, I agree not to departmentalize math or reading
instruction in 4th or 5th grades in the 2018–2019 or 2019–2020 school years.
• I agree to cooperate with and support data collections for the study, no matter which group my school is
assigned to. If my school is selected to departmentalize, I agree to participate in design meetings with the study
team to plan the transition to departmentalized instruction.
Details About Our School
Please provide the number requested or answer yes/no for each question in the table below.
Grade 4

Grade 5

1. Based on projected student enrollment, how many general education classrooms do you
expect to have in the 2018–2019 school year?
2. Do you have access to the following (yes/no):
Each classroom’s average scores on commercial assessments (such as NWEA, DIBELS,
assessments tied to a curriculum, etc.) from some time in the past two years?
Each classroom’s average scores on assessments your teachers developed some time in
the past two years?
Any information about teachers’ majors or subject-matter coursework in either
undergraduate or graduate school?
Affirmation of Commitment
Please sign your name: ___________________________________________________________
Please print your name: __________________________________________________________
Please print your title: ___________________________________________________________
Please print the name of your school: _______________________________________________
Please print the name of your district: _______________________________________________
Best email address to reach you: ___________________________________________________
Best phone number to reach you: __________________________________________________
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 form is estimated to average 15 minutes. 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.