Attachment O. CPM consent form for additional progam staff

attachment O
EDIT CONSENT FORM FOR ADDITIONAL PROGRAM STAFF

THE Examining data informing teaching (EDIT) development PROJECT

consent form FOR ADDITIONAL PROGRAM STAFF IN THE CLASSROOM

What is the purpose of the research study?	The purpose of the study is to develop a new research tool to help us learn how teachers assess children in their classrooms and use the information to tailor classroom instruction. The project is sponsored by the Administration for Children and Families in the U.S. Department of Health and Human Services.
Who is being invited to participate in the research study?	The pretest of the measure will involve teachers and children in 9 early childhood classrooms. Participation is voluntary; refusal to participate in the study will not negatively affect your relationship with your program. Even if you agree to participate in the study, you may withdraw at any time.
When will the research study be conducted?	The study activities will take place between December 2015 and May 2016.
What information will be collected?	The study may collect information about children in your class in two ways: (1) video-recordings of a teacher administering assessments and instruction to children in your class and (2) reviewing assessment and instruction information that the teacher has collected about children in your class. We are asking for your consent in case your image or voice appear in one of the videos that we are collecting. All the information we collect will be used for research and educational purposes only.
Who is conducting the research study?	Mathematica Policy Research is conducting the study for the Administration for Children and Families. Mathematica is a nationally recognized, nonpartisan research organization that conducts studies in early childhood education and other public policy areas. Additional information about Mathematica can be found online at http://www.mathematica-mpr.com.

How will Mathematica protect the privacy of research study participants?	Mathematica is committed to respecting the privacy of everyone who contributes to this study. All information will remain private to the extent permitted by law. Names will never be associated with or identified in study reports.
How can I get more information about the research study?	If you have any questions or would like more information about the study, please contact Shannon Monahan at Mathematica at 609-275-2207, or via email at smonahan@mathematica-mpr.com.
An agency may not conduct or sponsor, and a person is not required to respond to, a collection of information unless it displays a currently valid OMB control number. The OMB control number for this collection is 0970-0355 and it expires 03/31/2018. Please read the following statements, check the appropriate box, and complete the bottom section.  Yes, I agree that the EDIT observers may view the video-recordings that I may appear in. I understand these video-recordings may be used for research and educational purposes and give permission for use. I will receive no proceeds or compensation for the use of the video-recordings for these research or educational purposes or for the research tool’s future revisions, editions, translations, adaptations, and other formats. I may withdraw this consent at any time. The videos and recordings will be stored by Mathematica until the project ends and they are no longer required, at which time they will be destroyed. I have read this form and have received a copy for my records.  No, I do not give permission for my voice or image to appear in a video-recording. I have read this form and have received a copy for my records. Printed Name Signature Date