Consent Form

APPENDIX G

School and District Personnel Consent Form

EMT IRB Approval Date; _____/ _____ / _____

School and District Personnel Consent to Participate

in the State Bullying Laws and Policies Implementation Study

STUDY TITLE: State Bullying Laws and Policies Implementation Study

STUDY DIRECTOR: J. F. Springer, Ph.D., Project Director,

EMT Associates, Inc.

771 Oak Avenue Parkway, Suite 2

Folsom, CA 95630

(916) 983-6680

The U.S. Department of Education Policy is sponsoring a study about bullying in schools. Your school district was randomly selected for inclusion in the study as one of 24 case study sites in four U.S. states. The purpose of the study is to find out how districts and schools are implementing state laws and policies related to bullying. We are asking you to contribute to this important study by sharing your observations about bullying among students on your school campus, your experiences responding to bullying behavior, and your insights regarding the application and effectiveness of policies that are being used to combat bullying behavior.

INTERVIEW PROCEDURES

You are invited to participate in this study because you are a school or district employee who may be knowledgeable about bullying practices in your district or on your school campus. If you choose to participate, you will be asked to participate in a one-on-one interview about your school with a member of our study team. The interview will require approximately 45 minutes to 1 hour of your time. Study staff will work with you to coordinate a timeframe in which you will need to complete the interview.

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 for developing effective policies for responding to bullying in schools.

CONFIDENTIALITY

We will protect your privacy by not releasing information that identifies you outside the study team except as required by law. No one in your school or district administration will be told of your responses to interview questions and your responses will not be tied to any review or evaluation of your professional performance.

The names of all interview respondents will be separated from their interview responses as the data is entered into the database and will be used for data collection purposes only. As information is gathered from respondents or from sites, each respondent will be assigned a unique identification number. We will ensure that no individual, school, or district names are identified in reports or findings, and if necessary, we will mask distinguishing characteristics. Responses will be used to summarize findings in an aggregate manner (e.g., across types of schools or districts) and to provide examples of program implementation in a manner that does not associate responses with a specific individual or site.

If you agree to complete the interview, you will be considered a participant in a research study on the implementation of state bullying laws and policies and the research team will keep records of your responses for five years. During this time, the information you have provided will be kept in a protected computer file or in a locked filing cabinet. We will shred all interview protocols, forms, and other hardcopy documents containing identifiable data as soon as the need for this hard copy no longer exists. We will also destroy any data tapes or disks containing sensitive data.

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 study, you may contact Dr. Elizabeth Harris, Institutional Review Board Coordinator, toll-free at 1-866-XXX-XXXX. Thank you.

PLEASE CHECK THE BOXES BELOW

□ YES, I Received a copy of the School and District Personnel Consent to Participate in the State Bullying Laws and Policies Implementation Study and understand the information provided to me.

Signature		Date

_____ 3