Appendix E: Consent Forms (sample)

Please refer to your state’s and locality’s informed consent laws in deciding which consent form to use.

Dear parent/guardian:

<Education Agency> is conducting a voluntary survey about school climate. The survey will be administered to students during regular school hours during the week of <WEEK OF ADMINISTRATION>. It will ask students about their perceptions on topics such as student engagement, school environment, and school safety.

The data your child provides may also be used by the school and district to better understand the current climate in their school. The only people who will see your child’s answers to individual questions are authorized personnel at their school and district. Your child’s answers will be combined with the answers of other students at their school and district and used to create records about the climate of their school. These reports will not identify any person or their responses.

If you do not want your child to participate in this survey, please complete, sign, and postmark this letter using the enclosed postage-paid envelope by <DEADLINE DATE>. If you sign and postmark this letter by <DEADLINE DATE>, it means your child will not participate in the survey and will be asked to report to a designated place in the school (for example, the library) while the survey is being administered.

If you have any questions about this study or about your child’s participation or would like to see a copy of the student survey, please contact <ADMINISTRATOR NAME> at <ADMINISTRATOR NUMBER>. If you have any questions about your child’s rights as a participant in this study, please contact <SCHOOL CONTACT INFO>.

I understand that by completing and signing the form below and returning this letter, my child will not be allowed to take the School Climate Survey.

Parent/Guardian Signature: _______________________    Date: _______________________

Student Signature:_______________________________    Date: _______________________

Student Printed Name:____________________________    Date of birth: ________________

If you agree to allow your child to take the survey, you do not have to sign or send back anything.

Sincerely,

<ADMINISTRATOR NAME>

Dear parent/guardian:

<Education Agency> is conducting a voluntary survey about school climate. The survey will be administered to students during regular school hours during the week of <WEEK OF ADMINISTRATION>. It will ask students about their perceptions on topics such as student engagement, school environment, and school safety.

The data your child provides may also be used by the school and district to better understand the current climate in their school. The only people who will see your child’s answers to individual questions are authorized personnel at their school and district. Your child’s answers will be combined with the answers of other students at their school and district and used to create records about the climate of their school. These reports will not identify any person or their responses.

If you agree to allow your child to participate in this survey, please complete, sign, and postmark this letter using the enclosed postage-paid envelope by <DEADLINE DATE>. If you sign and postmark this letter by <DEADLINE DATE>, it means your child will participate in the survey and will be asked to report to a designated place in the school (for example, the computer lab) where the survey will be administered.

If you have any questions about this study or about your child’s participation or would like to see a copy of the student survey, please contact <ADMINISTRATOR NAME> at <ADMINISTRATOR NUMBER>. If you have any questions about your child’s rights as a participant in this study, please contact <SCHOOL CONTACT INFO>.

I understand that by completing and signing the form below and returning this letter, my child will be allowed to take the School Climate Survey.

Parent/Guardian Signature:_______________________    Date: _______________________

Student Signature:_______________________________    Date: _______________________

Student Printed Name:___________________________    Date of birth: ________________

If you do not want your child to take the survey, you do not have to sign or send back anything.

Sincerely,

<ADMINISTRATOR NAME>

American Institutes for Research

U.S. Department of Education

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