School Survey

Project LAUNCH School Survey

INFORMED CONSENT FORM FOR RESEARCH PARTICIPATION
PROJECT LAUNCH SCHOOL SURVEY*

We are conducting a study to learn about the social and emotional development of children from birth to eight years of age. This study is funded by the Substance Abuse and Mental Health Services Administration (SAMHSA), an agency within the U.S. Department of Health and Human Services (HHS). By surveying administrators of selected elementary schools and early childhood education programs, we seek to gain a better understanding of how frequently and why children are suspended and expelled from their schools/programs.

If you choose to participate, you will be asked to fill out a brief survey, which will take 20 minutes to complete the survey and up to 40 minutes to collect information to inform your responses. We plan to conduct this survey annually for two years and hope you will participate in the survey each year.

There are no risks in participating in this research beyond those experienced in everyday life. However, some of the questions are personal and may make you uncomfortable. Your participation in this study is voluntary. You can stop at any time, and you do not have to answer any questions you do not want to answer. Refusal to take part in or withdrawing from this study will not involve any penalty or loss of benefits you would receive otherwise.

Your responses will be kept private to the extent permitted by law. All findings will be reported in aggregate. If there are any publications or presentations resulting from this research, no personally-identifiable information will be shared because your name will not be linked to your answers. If you choose to withdraw from the study, we will maintain and analyze the data collected up to the time of withdrawal. However, if you request that we destroy all of your data and exclude your responses from the study results, we will honor your request.

Please contact Shannon TenBroeck, a member of the evaluation team at NORC, at (415) 315-2006 with questions, complaints, or concerns about this research. If you have any questions about your rights as a research participant, please contact the NORC Institutional Review Board (IRB) Manager by toll-free phone number at (866) 309-0542.

You must be 18 years of age or older to take part in this research study. If you agree to take part in this research study, please sign your name and indicate the date below. You will be given a copy of this consent form for your records.

_____________________________________________ _____________________

Participant Signature Date

Contacting you about future research:

This study will collect data from the same group of individuals once per year for a total of two years. As such, we plan to keep your contact information on file for two years and contact you about participating in future parts of this study.

If you are interested in participating in future parts of this study and agree to your contact information being held in a secure location, please initial below.

_______________

Participant Initials

* The informed consent will be incorporated into the web survey. In lieu of a signature, respondents will be asked to click an “I consent” button in the survey.

An agency may not conduct or sponsor, and a person is not required to respond to, a collection of information unless it displays a currently valid OMB control number. OMB number: 0970-0373; Expiration date: XX/XX/XXXX

Project LAUNCH School Survey

Background

1. School/ECE Name: ____________________________________

2. What is your role in the school/ECE?

   • Principal

   • Vice Principal

   • Director

   • Administrator

   • Support staff

   • Other. Please describe: ________________

3. Has your school/ECE been involved in Project LAUNCH activities?

   • Yes

   • No

   • I don’t know

4. Is a mental health consultant available to teachers in your school/ECE?

   • Yes

   • No

If NO, skip to question 9. If YES, answer questions 5-7.

5. Has the mental health consultant provided classroom-based strategies for dealing with challenging behavior?

   • Yes

   • No

6. Can you provide the name of the teachers who have received classroom consultations?

   • Please list grade and teacher’s names

7. Has the mental health consultant provided other services?

   • Yes

   • No

If NO, skip to question 9. If YES, answer question 8.

8. What other services has the mental health consultant provided?

• Written resource information to teachers or parents

• Modeled appropriate behavior with child or group

• Screened child/children for various mental health conditions

• Met with parent(s) individually or with parent and teacher to discuss child

• Referrals to parents for other services

• Conducted training and/or provided supervision for teachers and/or other staff

• Conducted workshops and/or educational classes for parents

• Led parent support groups

• Attended scheduled meetings (e.g., parent-teacher conferences, IEP meetings, staff meetings)

• Conducted play therapy and/or parent-child interaction therapy

• Other. Please describe: __________________________________

School Suspension

9. During the last full school year, how many children were enrolled in each age or grade level of your school/ECE?

• Early childhood education (skip unless the school includes early care services)

• Infant _________

• Age 1 _________

• Age 2 _________

• Age 3 _________

• Age 4 _________

• Age 5 preschool __

• Elementary School (skip if location is an early childcare center outside of an elementary school)

• Kindergarten _________

• First Grade _________

• Second Grade _________

• Third Grade _________

10. During the last full school year, how many children were suspended for behavioral reasons in each age group or grade level?

• Early childhood education (skip unless the school includes early care services)

• Infant _________

• Age 1 _________

• Age 2 _________

• Age 3 _________

• Age 4 _________

• Age 5 preschool __

• dElementary School (skip if location is an early childcare center outside of an elementary)

• Kindergarten _________

• First Grade _________

• Second Grade _________

• Third Grade _________

11. Please rank the following reasons for suspension from the most common reason for suspension to the least common reason.

• Violence toward others

• Disruptive behaviors

• Inappropriate behavior/play

• Inability to function independently

• Other. Please explain: _________________________

School Expulsion

12. During the last full school year, how many children were expelled (or involuntarily unenrolled) for behavioral reasons in each age group or grade level? (This does not include students removed for financial reasons, or those who had registered out of school zone)

Early childhood education (skip unless the school includes early care services)

• Infant _________

• Age 1 _________

• Age 2 _________

• Age 3 _________

• Age 4 _________

• Age 5 preschool _________

Elementary School (skip if location is an early childcare center outside of an elementary school)

• Kindergarten _________

• First Grade _________

• Second Grade _________

• Third Grade _________

13. Please rank the following reasons for suspension from the most common reason for suspension to the least common reason.

• Violence toward others

• Disruptive behaviors

• Inappropriate behavior/play

• Inability to function independently

• Other. Please explain: _________________________

v.2