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Appendix A

Approved Teacher Consent and Demographic Form
APPROVED BY

INTEGREVIEW ETHICAL REVIEW BOARD

JULY 10, 2013

2

INFORMED CONSENT TO PARTICIPATE IN THE RESEARCH STUDY

Introduction

This project is intended to evaluate a mathematics professional development program (PD) for grade 4 teachers called 

Developing Mathematical Ideas (DMI). The research study will examine outcomes for both teachers and their students.

There is currently little scientific evidence that math professional development provided to teachers actually helps to 

improve student achievement. This study hopes to fill in this important gap in our scientific knowledge of an important 

and wide-spread educational practice.

This study is a randomized controlled trial, where schools will be randomly (like the flip of a coin) assigned to receive 

DMI, or to receive math PD as typically provided in the district. This type of experiment provides the strongest evidence 

of whether PD delivered to teachers may have an impact on student achievement. You cannot choose which education 

type your school will receive. 

Study Funding and Personnel

This study is funded by Regional Educational Laboratory Southeast at Florida State University through a contract with the 

U.S. Department of Education and will be conducted by the employees and subcontractors of REL Southeast. 

How Long The Study Will Last and How Many People Will Be In The Study

Fourth grade teachers in 84 rural, suburban and urban schools in 3 districts in South Carolina and in 3 districts in Georgia 

will participate in the study which will last about a year.

Confidentiality:

REL Southeast will protect the confidentiality of all information collected for the study and will use it for research 

purposes only. No information that identifies any study participant will be released. Information from participating 

institutions and respondents will be presented at aggregate levels in reports. Information on respondents will be linked to 

their institution but not to any individually identifiable information. No individually identifiable information will be 

maintained by the study team after approval of the final report. Staff working on the project have signed confidentiality 

pledges and been screened for data security through the U.S. Department of Education e-qip system. Only persons 

conducting this study and maintaining and monitoring its records will have access to the records collected that contain 

individually identifying information.

REL Southeast will be following the new policies and procedures required by the Education Sciences Reform Act of 

2002, Title I, Part E, Section 183 requires "All collection, maintenance, use, and wide dissemination of data by the 

Institute" to "conform with the requirements of section 552 of title 5, United States Code, the confidentiality standards of 

subsection (c) of this section, and sections 444 and 445 of the General Education Provision Act (20 U.S.C. 1232g, 

1232h)." These citations refer to the Privacy Act, the Family Educational Rights and Privacy Act, and the Protection of 

Pupil Rights Amendment. 

Under the General Education Provision Act, Subsection (d) of section 183 prohibits disclosure of individually identifiable 

information as well as making the publishing or communicating of individually identifiable information by employees or 

staff a felony.

TID# _____________

(for study staff only)
APPROVED BY

INTEGREVIEW ETHICAL REVIEW BOARD

JULY 10, 2013

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The Institutional Review Board (IRB), IntegReview, and accrediting agencies may inspect and copy your 

records, which may have your name on them. Therefore, total confidentiality cannot be guaranteed. If 

the study results are presented at meetings or printed in publications, your name will not be used.

Benefits

If you choose to participate in this study and your school is placed in the experimental condition, you 

will be exposed to the DMI professional development, which may improve your knowledge of teaching 

math and ability to teach mathematics. Your participation in the study will assist in evaluating the 

effectiveness of the DMI professional development. Information learned from this study may assist in the 

improved design of instruction for future mathematics education. 

Alternatives To Participating In The Study 

Since this study is for research only, the only other choice would be not to be in the study. 

Costs

There will be no added costs for the curriculum and education and no additional costs for participation in 

this study. 

Volunteering To Be In The Study

Participation of teachers in the study is voluntary and not a condition of employment. You do not have to 

participate in this study, and you can change your mind at any time. There will not be any penalty or loss 

of benefits to you if you decide not to participate in this study or to leave this study. If you leave the 

study early, you will be paid for each form/activity completed at the time of your withdrawal. If you want 

to stop participating in the study, tell the study staff and he or she will terminate your participation in the 

study. If you leave the study, no more information about you will be collected for this study. However, 

all of the information you gave us before you left the study will still be used for research purposes only. 

The information we collect, including student scores on the math test, will not be used to evaluate your 

performance.

Random Assignment and Time Commitment 

This is a random assignment study, the gold standard of research designs. However this design is 

vulnerable to potential bias in the findings if participants know ahead of time what experimental condition 

they are in. This is because people may make different decisions on participation based on this 

knowledge, violating the intent that group membership be ‘random’ and not determined by other factors.

Therefore we are asking that you commit to participation in the study before you know the experimental 

condition your school will be assigned to. This is critical for the scientific validity of the results. The 

table below clearly lays out the time-commitment you will be agreeing to in advance, with the actual 

amount determined eventually by random assignment of your school.

Ultimately the schools participating from your district will each be paired with a similar school in the 

district. Each school in the pair will have a 50% chance of being assigned to receive DMI, and a 50% 

chance of being assigned to the Control condition. It is important that you completely understand the time 

commitments for both conditions in this study before agreeing to participate. You are committing to 

participate in whichever condition your school is assigned to.

TID# _____________

(for study staff only)
APPROVED BY

INTEGREVIEW ETHICAL REVIEW BOARD

JULY 10, 2013

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Time Commitments for each condition in the study.

Participation Activities Time Commitment Condition

DMI Control

Consent & Demographic Form 10 minutes X X

Teacher Knowledge, Pre- & Post-Test

2 X 2 hours 

Proctored on-site

(+ transit time)

X X

DMI – Sessions

8 X 3 hours

Weekday

(≈ 24 hours)

X

DMI – Homework 7 X 3 hours

(≈ 21 hours) X

 A total of 8 release days from instruction will be granted for DMI 

teachers to attend sessions and complete homework assignments.

Monthly PD Survey 9 X 12 minutes 

Online X X

Allowing student group to take post-test 45 minutes

In classroom X X

TOTAL Estimated participation time ≈ 52 

hours

≈ 7 

hours

Legal Rights

You will not lose any of your legal rights by signing this consent form.

Consent for Participation

I, _______________________________________, a 4th grade teacher at 

________________________________________ hereby agree to participate in the Math Fractions 

Professional Development study, conducted by the Southeast Regional Educational Laboratory at Florida 

TID# _____________

(for study staff only)

TID# _____________

(for study staff only)
APPROVED BY

INTEGREVIEW ETHICAL REVIEW BOARD

JULY 10, 2013

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State University, and its subcontractor Instructional Research Group, 4281 Katella Ave., Los Alamitos, 

CA.

Remuneration:

I understand I will be paid $150.00 for completing the forms and activities in the table on the previous 

page. This represents a typical rate paid in the state for time outside of the regular teacher contract with 

the district. Regardless of how much time is actually spent completing measures and activities, I 

acknowledge that these estimates were made in good faith by the research team and represent the 

remuneration I will be paid for participation, if I complete all activities as scheduled. If I leave the study 

early, I will be paid for each form/activity completed at the time of my withdrawal.

I understand that if my school is randomly assigned to participate in the PD condition, I will be granted 

by the district/school up to 8 release days from instruction to participate in 8 3-hour DMI training sessions 

and subsequent required homework activities.

I further understand that my participation will continue only as long as it is mutually agreeable and 

that I can end my participation at any time. Final remuneration would, however, be based on the 

activities completed. I agree that study staff may contact me to follow-up on activities and for scheduling 

purposes. I was offered a copy of this consent form for my records. 

If I have further questions about this study or my rights, I can contact the study manager, Madhavi 

Jayanthi, by telephone at (714) 826-9600 or e-mail (madhavi@inresg.org). 

If I do not want to talk to the investigators or study staff, if I have concerns or complaints about the 

research, or to ask questions about my rights as a study subject, I may contact IntegReview. IntegReview’s 

policy indicates that all concerns/complaints are to be submitted in writing for review at a convened IRB 

meeting to:
APPROVED BY

INTEGREVIEW ETHICAL REVIEW BOARD

JULY 10, 2013

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 Mailing Address: OR Email Address:

Chairperson

IntegReview

3001 S. Lamar Blvd., Suite 210

Austin, Texas 78704

integreview@integreview.com

If I am unable to provide my concerns/complaints in writing or if this is an emergency situation regarding

subject safety, I should contact their office at:

512-326-3001 or 

toll free at 1-877-562-1589

between 8 a.m. and 5 p.m. Central Time 

IntegReview has approved the information in this consent form and has given approval for the 

investigators to do the study. This does not mean IntegReview has approved my being in the study. I

must consider the information in this consent form for myself and decide if I want to be in this study.

__________________________________ ________________________________________

Teacher’s Signature Date

__________________________________ (Street)

__________________________________ (City, State, ZIP)

Phone and e-mail for follow-up: 

Phone: (__ __ __) __ __ __ - __ __ __ __

Email: __________________@___________.______

TID# _____________

(for study staff only)
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Teacher Demographic Questionnaire

This demographic questionnaire is to be completed at the same time as the consent form. All responses 

will held strictly confidential as described above.

Name: _________________________________ School: _________________________________

Gender (Circle One) Male Female

Degrees (please list all completed, specifying major):

BA: __________________________________

MA: __________________________________

Post-MA: ______________________________

Other: ________________________________________________

Years Teaching In-service (please enter whole years, rounded up):

Total Years of Classroom Teaching Experience ____

Total Years of 4th grade Classroom Teaching Experience ____

Total Years Teaching in Current School ____

Total Years Teaching Math in Middle/High School (Grades 6-12) ____

Your certifications (please check all that apply):

Elementary ____ 

Middle School ____

Mathematics ____

Math Specialist ____

Reading Specialist ____

Bilingual Education ____

Special Education ____

Speech/Language Specialist ____

Alternative Certification ____

Administrative ____

Other: __________________________________

TID# _____________

(for study staff only)