OMB Control Number XXXX-XXXX (Exp XX/XX)

REL Midwest Ramp-Up to Readiness Staff Consent Form

20 East Diehl Road, Suite 200 | Naperville, IL 60563-1486 | P: 866.730.6735 F: 630.649.6700

www.relmidwest.org

Staff Consent Form

Purpose

Our school has partnered with the Regional Educational Laboratory (REL) Midwest to study the 

implementation of a schoolwide guidance program called Ramp-Up to Readiness (“Ramp-Up”) 

developed by the College Readiness Consortium at the University of Minnesota. REL Midwest, 

operated by American Institutes for Research, is sponsored by the Institute of Education Sciences 

(IES) at the U.S. Department of Education. The evaluation will examine how school staff 

implement Ramp-Up and how the intervention compares with college-readiness supports in other 

high schools. The study has been submitted to IES for research approval. The data collection 

activities have also been approved by the U. S. Office of Management and Budget.

REL Midwest invites you to complete the following online survey.

Voluntary Participation

Participation in all data collection activities is voluntary. You also can withdraw from the study

at any time. Individuals who decline to participate or later withdraw from the study will face no 

personal or professional repercussions.

Risks 

There are few anticipated or known risks in participating in this study. Data collected and 

maintained by, or under the auspices of, IES under a pledge of confidentiality shall be treated in 

a manner that will ensure that individually identifiable data will be used only for statistical 

purposes and will be accessible only to authorized persons.

According to the Paperwork Reduction Act of 1995, no persons are required to respond to a collection of information unless it displays a valid 

OMB control number. The valid OMB control number for this information collection is XXXX.XXXX, OMB expiration date is XXXX, XX, 2014. 

The time required to complete this information collection (consent form) is estimated to average 5 minutes per respondent, including the time to 

review instructions, gather the data needed, and complete and review the information collected. Participation in this data collection task is voluntary.

Per the policies and procedures required by the Education Sciences Reform Act of 2002, Title I, Part E, Section 183, responses to this data 

collection will be used only for statistical purposes. The reports prepared for this study will summarize findings across the sample and will not 

associate responses with a specific school, district, or individual. Any willful disclosure of such information for nonstatistical purposes, except as 

required by law, is a class E felony.

If you have any comments concerning the accuracy of the time estimate(s) or suggestions for improving this form, please write to: U.S. 

Department of Education, Washington, DC 20202. If you have comments or concerns regarding the status of your individual submission of this 

form, write directly to: U.S. Department of Education, Institute of Education Sciences, 555 New Jersey Avenue, NW, Washington, DC 20208.
Benefits

Your participation in the evaluation will contribute to an understanding of a schoolwide college 

readiness program that seeks to improve the college readiness outcomes of all students. You will 

also receive a $25 gift card from Amazon.com for participating in the data collection activities.

Confidentiality

Your responses will not be connected to your personally identifiable information. Responses to 

this data collection will be used only for statistical purposes. The reports prepared for this study

will summarize findings across the sample and will not associate responses with any specific 

individual. The researchers will not provide information that identifies you or your school to 

anyone outside the study team, except as required by law.

More Information

If you would like more information about this study, you may contact Jim Lindsay of REL

Midwest at 630-649-6591.

Informed Consent

By signing this form, you are indicating that you have read and understood the information 

provided to you about your participation.

Yes, I want to participate in this study.

Yes, I give permission to be audiorecorded during a focus group.

No, I do not wish to participate in this study.

Print Name: _______________________________________________________________

Signature: ________________________________________________

Date: __________________

School Name: __________________________________________________________