National Study to Inform the 21st Century Community Learning Centers (CCLC) Program

Appendix E:

Parent or Guardian Permission Form

OMB No.: xxxx-xxxx Expiration Date: xx/xx/xxxx

Dear Parent or Guardian,

The U.S. Department of Education is sponsoring the National Study of Continuous Quality Improvement to Inform the 21st Century Community Learning Centers Program. The goal of the study is to learn about ways in which afterschool centers can improve their programs. Mathematica is conducting the study for the U.S. Department of Education.

I am writing to request permission for your child to be included in the following important data collection activities. The study team would like to:

• Give your child a brief 10-minute survey to ask about their afterschool activities and what they think about the behavior of made-up children who are described in the survey. The survey will be given in spring 2022 and spring 2023.

• Collect records from the afterschool center that contain information on your child’s afterschool attendance during the 2021-2022 and 2022-2023 school year.

• Collect records from the school district that contain information on your child’s attendance, behavior, test scores, participation in school services, and demographic information from the 2020-2021 through 2022- 2023 school years.

• Ask your child’s teacher to complete a brief 10-minute survey about your child’s classroom behavior and grades in English language arts and math.

Please know that there is no risk to your child from participating in the study because:

• your child’s identity, as well as that of other students, schools, and teachers, will be in the study data but will be kept confidential. The study will summarize information across students and will not present information on any individual students. Your child’s data are protected by the Education Sciences Reform Act of 2002, Title I, Part E, Section 183.

• your child’s data will only be viewed by the study team (it will not be shared with the school, district, or afterschool program), except as required by law; and

• data collected during the study will be destroyed at the end of the study.

Allowing your child to be included in this study is voluntary. Refusing permission will in no way affect your child’s grades or participation in the afterschool center. If you allow your child to be included in this study, you or your child can choose to stop participation at any time.

Please let us know whether you will allow your child to be included in the study by completing the attached pink form. If you give permission for your child to be included in the study, please check “yes” and sign the attached pink form and return it to your child’s afterschool staff by [month] [day]. Please keep the blue form and this letter for your records. If you have questions about this study or about your child's participation, please call Kristina Rall, the study’s Survey Director, toll-free, at [1-XXX-XXX-XXXX] between 9 a.m. and 5 p.m. Eastern Time, Monday-Friday or email the study team at [STUDY EMAIL]@mathematica-mpr.com].

Sincerely,

Paperwork Reduction Act Statement - This information collection meets the requirements of 44 U.S.C. § 3507, as amended by section 2 of the Paperwork Reduction Act of 1995. You do not need to answer these questions unless we display a valid Office of Management and Budget control number. The OMB control number for this information collection is XXXX-0XXX, expiring xx-xxx-20xx. We estimate that it will take about 5 minutes to read the instructions, gather the facts, and answer the questions. 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. Send only comments relating to our time estimate to this address, not the completed form.

Susanne James-Burdumy, Ph.D. Project Director

OMB No.: xxxx-xxxx Expiration Date: xx/xx/xxxx

National Study of Continuous Quality Improvement to Inform the 21st Century Community Learning Centers Program

PARENT/GUARDIAN PERMISSION FORM

Fall 2021

Please complete the following form and return it to the afterschool center staff.

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 the study.

OR

NO, I do not give permission for my son/daughter to be included in this study.

YOUR CHILD’S NAME DATE

PARENT OR GUARDIAN SIGNATURE

PARENT OR GUARDIAN NAME (PLEASE PRINT)

Paperwork Reduction Act Statement - This information collection meets the requirements of 44 U.S.C. § 3507, as amended by section 2 of the Paperwork Reduction Act of 1995. You do not need to answer these questions unless we display a valid Office of Management and Budget control number. The OMB control number for this information collection is XXXX-0XXX, expiring xx-xxx-20xx. We estimate that it will take about 5 minutes to read the instructions, gather the facts, and answer the questions. 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. Send only comments relating to our time estimate to this address, not the completed form.