### APPENDIX A

PRINCIPAL AND TEACHE R CONTACT FORMOMB Control No.: ####

- #### Expiration Date: ##/##/#### ####

- ###



## TEACHER AND PRINCIPAL CONTACT INFORMATION

T he Evaluation of the Teacher Incentive Fund (TIF) will be conducting teacher and principal survey s in spring 20 12, 2013, 2014, and 2015 to collect information on your educational back ground, career history , and experience with your school’s use of performance

- based compensation

. As an educator at one of the schools in the study sample , we are requesting y our contact information in case we have follow

- up questions and you are no longer at your current school.

Providing th is information is voluntary and w e will only use it to help us contact you to complete the survey if you leave your
current school.

Please PRINT your name, home address, telepho ne number ( s ) and email address ( es )

.
Y our Full Name :

________________________________ ________________________________ ____________________

Home S treet Address :

________________________________ ________________________________ _______________

C ity :

________________________________ __ S tate :

__________ Z ip Code :

__________

Home email address:

__________________________ Work email address:

_________________________
Home phone #: |___|___|___|

- |___|___|___|

- |___|___|___|___|

Cell phone #: |___|___|___|

- |___|___|___|

- |___|___|___|___|

Work phone #: |___|___|___|

- |___|___|___|

- |___|___|___|___|

What are the names and addresses of TWO other people who would know where to get in touch with you? Please do not list any person who lives with you

.

(1) First Person
Name :

________________________________ ________________________________ _______________ Relationship to you :

________________________________ ________________________________ _____ S treet Address :

________________________________ ________________________________ ________ C ity :

________________________ S tate :

___________ Z ip Code :

_________
Home phone #: |___|___|___|

- |___|___|___|

- |___|___|___|___|

Cell phone #: |___|___|___|

- |___|___|___|

- |___|___|___|___|

(2) Second Person
Name :

________________________________ ________________________________ _______________ Relationship to you :

________________________________ ________________________________ _____ S treet Address :

________________________________ ________________________________ ________ C ity :

________________________ S tate :

___________ Z ip Code :

_________
Home phone #: |___|___|___|

- |___|___|___|

- |___|___|___|___|

Cell phone #: |___|___|___|

- |___|___|___|

- |___|___|___|___|



### Thank you for completing this form. Please mail it to Mathematica in the envelope provided.OMB Control No.: ####

- #### Expiration Date: ##/##/#### ####

- ###
Notice of Confidentiality 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 district or individual. We will not provide information that identifies you or your district to a nyone outside the study team, except as required by law. Additionally, no one at your school or in your district will see your responses. While your participation in this study is voluntary, it is ve ry important that you complete the questionnaire.

Accord ing to the Paperwork Reduction Act of 1995, no persons are required to respond to a collection of information unless it displ ays a valid OMB control number. The valid OMB control number for this information collection is xxxx - xxxx . The time required to com plete this information collection is estimated to
average 5 minutes per respondent, including the time to review instructions, gather the data needed, and complete and review the inform ation collected. If you have any comments concerning the accuracy of th e 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, writ e directly to: U.S. Dep artment of Education, Institute of Education Sciences, 555 New Jersey Avenue, NW, Washington, DC 20208.