APPENDIX K_School Administrator Consent Form_OMB

APPENDIX K

School Administrator Consent Form

EMT IRB Approval Date; _____/ _____ / _____

School Administrator Consent to Complete the School Site Data Form

STUDY TITLE: Crime Prevention through Environmental Design (CPTED): Linking Observed School Environments with Student and School-wide Experiences of Violence and Fear

STUDY DIRECTORS: J.F. Springer, Ph.D., Project Director, EMT Associates, Inc.

Rená Agee, M.A., Project Director, ICF Macro

The Centers for Disease Control and Prevention (CDC) is sponsoring a study about violence in schools. The purpose of the study is to find out if perceptions of a school’s physical environments are associated with violent or aggressive behavior. We are asking you to provide information about the school, student schedules, school characteristics, school facilities, student and staff populations, characteristics of school policies, absenteeism, violent death and other incidents at school, and school violence prevention practices.

SURVEY PROCEDURES

You are invited to participate in this study because, as a school administrator, you have historical information necessary for the study. If you choose to participate, you will be asked to complete a survey about your school that will require approximately 2 hours of your time and study staff will work with you to coordinate a timeframe in which you will need to complete the survey.

POTENTIAL RISKS OR BENEFITS OF PARTICIPATION

There are no anticipated risks involved in taking part in this study. Participation may not benefit you personally. However, the information gathered in this study may be valuable in schools’ efforts to reduce crime and violence by (re)designing physical features of the environment and changing policies and procedures related to using the school environment.

CONFIDENTIALITY

We will protect your privacy by NOT including your name, your schools’ name, or any other identifying facts when we present the study or publish its results. The study findings will be summarized and reported in group form. The survey results will be kept private to the extent allowed by law, and only researchers on the study will have access to the information you provide. All personally identifying information will be destroyed following data analysis. If you agree to complete the survey, you will be considered a participant in this three-year research study; however, the research team will keep records of your responses for five years. During this time, the information you provided will be kept on a protected computer or in a locked filing cabinet.

VOLUNTARY PARTICIPATION/WITHDRAWAL

Your participation in the research study is completely voluntary. You may decide not to join, to only answer some questions, or to leave the study at any time. There is no penalty for choosing not to participate.

CONSENT

For more information about the study or if any part of this form was unclear to you, you may contact XXX at (XXX) XXX-XXXX. If you have questions about your rights as a participant in this research study, you may contact Dr. Elizabeth Harris, Institutional Review Board Coordinator, toll-free at 1-866-XXX-XXXX. Thank you.

PLEASE CHECK ONE OF THE BOXES BELOW

□ YES, I agree to participate in the CPTED School Study.

□ NO, I do not agree to participate in the CPTED School Study.

________________________________________________ ________________________________

Signature Date