20 East Diehl Road, Suite 200 | Naper ville, 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 Ameri can 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. An application also will be submitted to the Office of Management and Budget for review.

REL Midwest invit es you and other school staff to participate in the study, which will b egin this spring. The study involves the following data collection activities, which you may be asked to participate in :

 Two focus groups, one in February and one in May

 Short instructional logs following each of five Ramp

- Up college workshops

 An online s urvey in the spring 2014

Voluntary Participation

Participation in the 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 en sure that individually identifiable data will be used only for statistical purposes and will be accessible only to authorized persons.

Benefits

Your participation in the evaluation will contribute to an understanding of a schoolwide college readiness program th at 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

Responses to this data collection will be used only for statisti cal purposes. The reports prepared for this study will summarize findings across the sample and will not associate responses with

a ny 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:

__________________________________________________________

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 da te is XXXX, XX, 2014. The time required to complete this information collection is estimated to average 15 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 2020 2. If you have comments or concerns regarding the status of your individual subm ission of this form, write directly to: U.S. Department of Education, Institute of Education Sciences, 555 New Jersey Avenue, NW, Washington, DC 20208.