Impact Evaluation of Teacher Residency Programs

Appendix A

Classroom Roster Request Form

Impact Evaluation of Teacher Residency Programs Request Form for Assigning Students to Classes School Year [2021-2022/2022-2023]

In order for Mathematica to assign students to classrooms for fall [2021/2022], please do the following:

1. Complete this form (one new form for each classroom match). A classroom match is a group of classes of the same grade and subject, between which students are to be assigned.

2. Prepare the list/roster of students. Include each student’s first name, last name, student ID, and any student characteristics (such as gender or academic ability) you would like us to balance across classrooms. Please include student gender if there are no other characteristics you would like us to balance across classrooms.

3. Return this form and the list/roster of students using the link and instructions provided for the study’s secure file transfer site.

A. This form and the attached roster of students are for:

School Name:
District Name:
State:
Class Type:	□ General (may contain some special education or English learner students) □ Self-contained English learner class □ Self-contained bilingual class □ Other (specify) _______________________________					Subject(s):		□ English language arts □ Math □ Both English language arts and math
Grade: Please mark grade below. Select one only.
GRADE 3		GRADE 4		GRADE 5	GRADE 6		GRADE 7		GRADE 8
□ 3		□ 4		□ 5	□ 6		□ 7		□ 8
Day/Block/Family (if applicable):
Period/Time (if applicable):

B. Date classroom assignment lists should be sent back to the school: ______/____ / 20____

month day year

C. The attached list(s) of ______ students is to be divided into ______ classes.

number number

D. Please list first and last names of lead teachers expected to teach these classes.

Write “Unknown” if you do not know who the lead teacher will be or whether the lead teacher graduated from a teacher residency program.

	Teacher First Name	Teacher Last Name	Residency Program Graduate? (Y/N)
1.
2.
3.
4.
5.
6.

E. Assignment Criteria (optional): Indicate up to 3 criteria (such as gender or academic ability) that must be taken into account when assigning students to classrooms. Note: Because we are assigning students randomly, the classrooms will be automatically balanced on most criteria.

Number	Criterion	Codes Used	Code Meaning

F. Exceptions (optional): Describe any necessary exceptions to assignment lottery (for example, students who must be assigned to different classrooms or to a particular teacher). Such requests should not exceed 10 percent of students per class. Please clearly specify the names of the students and the assignment requests:

1
2
3
4
5

Impact Evaluation of Teacher Residency Programs Request Form for Assigning Students to Classes School Year [2021-2022/2022-2023]

EXAMPLE

In order for Mathematica to assign students to classrooms for fall [2021/2022], please do the following:

1. Complete this form (one new form for each classroom match). A classroom match is a group of classes of the same grade and subject, between which students are to be assigned.

2. Prepare the list/roster of students. Include each student’s first name, last name, student ID, and any student characteristics (such as gender or academic ability) you would like us to balance across classrooms. Please include student gender if there are no other characteristics you would like us to balance across classrooms.

3. Return this form and the list/roster of students using the link and instructions provided for the study’s secure file transfer site.

A. This form and the attached roster of students are for:

School Name:	Best Elementary School
District Name:	Middleton District
State:	NJ
Class Type:	 General (may contain some special education or English learner students) □ Self-contained English learner class □ Self-contained bilingual class □ Other (specify) _______________________________					Subject(s):		□ English language arts □ Math  Both English language arts and math
Grade: Please mark grade below. Select one only.
GRADE 3		GRADE 4		GRADE 5	GRADE 6		GRADE 7		GRADE 8
□ 3		□ 4		 5	□ 6		□ 7		□ 8
Day/Block/Family (if applicable):			Tuesday-Thursday, Block 2 (10:00-11:30 AM)
Period/Time (If applicable):			10:00-11:30 AM

B. Date classroom assignment lists should be sent back to the school: 06 / 30 / 2021

month day year

C. The attached list(s) of 60 students is to be divided into 3 classes.

number number

D. Please list first and last names of lead teachers expected to teach these classes.

Write “Unknown” if you do not know who the lead teacher will be or whether the lead teacher graduated from a teacher residency program.

	Teacher First Name	Teacher Last Name	Residency Program Graduate? (Y/N)
1.	William	Shakespeare	Y
2.	Jane	Austen	N
3.	Alice	Walker	N
4.
5.

E. Assignment Criteria (optional): Indicate up to 3 criteria (such as gender or academic ability) that must be taken into account when assigning students to classrooms. Note: Because we are assigning students randomly, the classrooms will be balanced on most criteria automatically.

Number	Criterion	Codes Used	Code Meaning
1	Gender	F	Female
		M	Male
2	English Language Learner	Y	Yes
		N	No

F. Exceptions (optional): Describe any necessary exceptions to assignment lottery (for example, students who must be assigned to different classrooms or to a particular teacher). Such requests should not exceed 10 percent of students per class. Please clearly specify the names of the students and the assignment requests:

1	Langston Hughes and George Orwell must be in separate classrooms
2	John Steinbeck must be placed in Mr. Shakespeare’s classroom
3	Toni Morrison and Richard Wrightmust NOT be separated
4
5

EXAMPLE EXAMPLE

STUDENT LIST / ROSTER (fictitious names listed below)

SCHOOL NAME: Best Elementary School, Middleton District

TOTAL NUMBER OF STUDENTS: 57

GRADE: GRADES 5

SUBJECT: ENGLISH LANGUAGE ARTS AND MATH Lead Teachers are: Shakespeare, Austen, and Walker

				Assignment Criteria
	First name	Last name	Student ID	Gender (criterion #1)	EL (criterion #2)
1	Virginia	Woolf	1000351	F	N
2	Richard	Wright	1000452	M	N
3	Charles	Dickens	1000600	M	N
4	Maya	Angelou	1000601	F	N
5	George	Orwell	1000502	M	Y
6	Alex	Haley	1000503	M	N
7	John	Steinbeck	1000901	M	Y
8	Phillis	Wheatley	1000111	F	N
9	Langston	Hughes	1000250	M	N
10	Agatha	Christie	1000605	F	N
11	W.E.B.	Du Bois	1000559	M	N
12	Toni	Morrison	1000669	F	N
13	Octavia	Butler	1000999	F	N
51	Lorraine	Hansberry	1000667	F	Y
52	Zora Neale	Hurston	1000553	F	Y
53	Ernest	Hemmingway	1000523	M	N
54	James	Joyce	2000783	M	N
55	August	Wilson	9000900	M	N
56	James	Baldwin	2000352	M	N
57	Kurt	Vonnegut	3000651	M	N