APPENDIX A

PRINCIPAL AND TEACHER CONTACT FORM
OMB Control No.: ####-#### Expiration Date: ##/##/#### ####-###

TEACHER AND PRINCIPAL CONTACT INFORMATION

The Evaluation of the Teacher Incentive Fund (TIF) will be conducting teacher and principal surveys in spring 2012, 2013, 

2014, and 2015 to collect information on your educational background, 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 your 

contact information in case we have follow-up questions and you are no longer at your current school.

Providing this information is voluntary and we 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, telephone number(s) and email address(es). 

Your Full Name: ____________________________________________________________________________________

Home Street Address: _______________________________________________________________________________

City: __________________________________ State: __________ Zip 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: _____________________________________________________________________

Street Address: ________________________________________________________________________

City: ________________________ State: ___________ Zip Code: _________

Home phone #: |___|___|___| - |___|___|___| - |___|___|___|___|

Cell phone #: |___|___|___| - |___|___|___| - |___|___|___|___|

(2) Second Person

Name: _______________________________________________________________________________

Relationship to you: _____________________________________________________________________

Street Address: ________________________________________________________________________

City: ________________________ State: ___________ Zip 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 anyone 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 very 

important that you complete the questionnaire.

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. The time required to complete 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 information collected. 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.