F–1

Draft OMB Clearance Request

Promoting Student Success in Algebra I

Appendix F: Consent Forms

February 2013
F–2

Promoting Student Success in Algebra I

Informed Consent: Principal Interview

Purpose

The Office of Elementary and Secondary Education (OESE) of the U.S. Department of Education (ED) 

requests clearance for the data collection for the Promoting Student Success in Algebra I (PSSA) study. 

The purpose of this study is to provide actionable information and greater insight into the knowledge 

and resources required to enable student success in mathematics between grades 6 through 9, with an 

emphasis on helping all students complete Algebra I by the end of the ninth grade. To this end, the 

evaluation will employ multiple data collection strategies.

To assist with the evaluation, we are asking principals to participate in interviews. You will be 

interviewed about best practices for improving student success in mathematics and Algebra I, in 

particular. The interviews are designed to last no more than one hour.

Risks and Discomfort

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

Benefits

Your participation in the evaluation will contribute to an understanding of how state and local education 

agencies can work to improve student outcomes in Algebra I.

Confidentiality

We will treat the information that you supply in a confidential manner. Only selected research staff will 

have access to data. We will NOT present results in any way that would permit them to be identified 

with you or any other specific individual. No personally identifiable information, such as name or district 

affiliation, will be disclosed to anyone outside the project.

More Information

If you would like more information about this study, you may contact the Project Director, Kirk Walters, 

at the American Institutes for Research at 202-403-5838 or at kwalters@air.org. For questions regarding 

your rights as a subject participating in this research, please contact the Institutional Review Board (IRB) 

at IRBChair@air.org or toll free at 1–800–634–0797.

Informed Consent

I have read the above information. I have asked questions and received answers. I consent to participate 

in the study.

Signature: ________________________________ Date: ________________________

Print Name: ______________________________ Position: _____________________

District/School: ____________________________
F–3

Promoting Student Success in Algebra I

Informed Consent: Principal Focus Group

Purpose

The Office of Elementary and Secondary Education (OESE) of the U.S. Department of Education (ED) 

requests clearance for the data collection for the Promoting Student Success in Algebra I (PSSA) study. 

The purpose of this study is to provide actionable information and greater insight into the knowledge 

and resources required to enable student success in mathematics between grades 6 through 9, with an 

emphasis on helping all students complete Algebra I by the end of the ninth grade. To this end, the 

evaluation will employ multiple data collection strategies.

To assist with the evaluation, we are asking principals to participate in a focus group. You will be 

interviewed about best practices for improving student success in mathematics and Algebra I, in 

particular. The interviews are designed to last no more than one hour.

Risks and Discomfort

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

Benefits

Your participation in the evaluation will contribute to an understanding of how state and local education 

agencies can work to improve student outcomes in Algebra I.

Confidentiality

We will treat the information that you supply in a confidential manner. Only selected research staff will 

have access to data. We will NOT present results in any way that would permit them to be identified 

with you or any other specific individual. No personally identifiable information, such as name or district 

affiliation, will be disclosed to anyone outside the project.

More Information

If you would like more information about this study, you may contact the Project Director, Kirk Walters, 

at the American Institutes for Research at 202-403-5838 or at kwalters@air.org. For questions regarding 

your rights as a subject participating in this research, please contact the Institutional Review Board (IRB) 

at IRBChair@air.org or toll free at 1–800–634–0797.

Informed Consent

I have read the above information. I have asked questions and received answers. I consent to participate 

in the study.

Signature: ________________________________ Date: ________________________

Print Name: ______________________________ Position: _____________________

District/School: ____________________________
F–4

Promoting Student Success in Algebra I

Informed Consent: Teacher Focus Group

Purpose

The Office of Elementary and Secondary Education (OESE) of the U.S. Department of Education (ED) 

requests clearance for the data collection for the Promoting Student Success in Algebra I (PSSA) study. 

The purpose of this study is to provide actionable information and greater insight into the knowledge 

and resources required to enable student success in mathematics between grades 6 through 9, with an 

emphasis on helping all students complete Algebra I by the end of the ninth grade. To this end, the 

evaluation will employ multiple data collection strategies.

To assist with the evaluation, we are asking teachers to participate in a focus group. You will be 

interviewed about best practices for improving student success in mathematics and Algebra I, in 

particular. The interviews are designed to last no more than one hour.

Risks and Discomfort

There are few anticipated or known risks in participating in this study. Risks may include possibly feeling 

coerced to take part in the focus group, however you should know that your participation in this study is 

entirely voluntary. You will not be penalized in any way for not participating. If you decide to participate, 

you may discontinue your participation at any time without penalty or loss of benefits to which you are 

otherwise entitled.

Benefits

Your participation in the evaluation will contribute to an understanding of how state and local education 

agencies can work to improve student outcomes in Algebra I.

Confidentiality

We will treat the information that you supply in a confidential manner. Only selected research staff will 

have access to data. We will NOT present results in any way that would permit them to be identified 

with you or any other specific individual. No personally identifiable information, such as name or district 

affiliation, will be disclosed to anyone outside the project.

More Information

If you would like more information about this study, you may contact the Project Director, Kirk Walters, 

at the American Institutes for Research at 202-403-5838 or at kwalters@air.org. For questions regarding 

your rights as a subject participating in this research, please contact the Institutional Review Board (IRB) 

at IRBChair@air.org or toll free at 1–800–634–0797.

Informed Consent

I have read the above information. I have asked questions and received answers. I consent to participate 

in the study.

Signature: ________________________________ Date: ________________________

Print Name: ______________________________ Position: _____________________

District/School: ____________________________
F–5

Promoting Student Success in Algebra I

Informed Consent: Parent Consent for High School Student Focus Group

Purpose

The Office of Elementary and Secondary Education (OESE) of the U.S. Department of Education (ED) 

requests clearance for the data collection for the Promoting Student Success in Algebra I (PSSA) study. 

The purpose of this study is to provide actionable information and greater insight into the knowledge 

and resources required to enable student success in mathematics between grades 6 through 9, with an 

emphasis on helping all students complete Algebra I by the end of the ninth grade. To this end, the 

evaluation will employ multiple data collection strategies.

To assist with the evaluation, we are asking high school students to participate in a focus group. You will 

be interviewed about best practices for improving student success in mathematics and Algebra I, in 

particular. The interviews are designed to last no more than one hour.

Risks and Discomfort

There are few anticipated or known risks in participating in this study. Risks may include possibly feeling 

coerced to take part in the focus group, however you should know that your child’s participation in this

study is entirely voluntary. Your child will not be penalized in any way for not participating. If your child 

decides to participate, he/she may discontinue their participation at any time without penalty or loss of 

benefits to which they are otherwise entitled.

Benefits

Your child’s participation in the evaluation will contribute to an understanding of how state and local 

education agencies can work to improve student outcomes in Algebra I.

Confidentiality

We will treat the information that your child supply in a confidential manner. Only selected research 

staff will have access to data. We will NOT present results in any way that would permit them to be 

identified with your child or any other specific individual. No personally identifiable information, such as 

name or district/school affiliation, will be disclosed to anyone outside the project.

More Information

If you would like more information about this study, you may contact the Project Director, Kirk Walters, 

at the American Institutes for Research at 202-403-5838 or at kwalters@air.org. For questions regarding 

your rights as a subject participating in this research, please contact the Institutional Review Board (IRB) 

at IRBChair@air.org or toll free at 1–800–634–0797.

Informed Consent

I have read the above information. I have asked questions and received answers. I consent to participate 

in the study.

Signature: ________________________________ Date: ________________________

Print Name: ______________________________ Child’s Name: _____________________

District/School: ____________________________
F–6

Promoting Student Success in Algebra I

Informed Consent: State Official Interview

Purpose

The Office of Elementary and Secondary Education (OESE) of the U.S. Department of Education (ED) 

requests clearance for the data collection for the Promoting Student Success in Algebra I (PSSA) study. 

The purpose of this study is to provide actionable information and greater insight into the knowledge 

and resources required to enable student success in mathematics between grades 6 through 9, with an 

emphasis on helping all students complete Algebra I by the end of the ninth grade. To this end, the 

evaluation will employ multiple data collection strategies.

To assist with the evaluation, we are asking state officials to participate in interviews. You will be 

interviewed about best practices for improving student success in mathematics and Algebra I, in 

particular. The interviews are designed to last no more than one hour.

Risks and Discomfort

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

Benefits

Your participation in the evaluation will contribute to an understanding of how state and local education 

agencies can work to improve student outcomes in Algebra I.

Confidentiality

We will treat the information that you supply in a confidential manner. Only selected research staff will 

have access to data. Our state-level data collections, by their very nature, focus on policy topics that are 

in the public domain. Moreover, it would not be difficult to identify Title I and school improvement 

directors in each state and thus determine the identity of our state-level respondents. Having 

acknowledged that, we will endeavor to protect the privacy of you, and as with district- and school-level 

respondents, we will avoid using your names in reports and attributing any quotes to specific 

individuals. We will primarily report on the numbers of schools that engage in specific practices, thus 

avoiding reference to specific schools.

More Information

If you would like more information about this study, you may contact the Project Director, Kirk Walters, 

at the American Institutes for Research at 202-403-5838 or at kwalters@air.org. For questions regarding 

your rights as a subject participating in this research, please contact the Institutional Review Board (IRB) 

at IRBChair@air.org or toll free at 1–800–634–0797.

Informed Consent

I have read the above information. I have asked questions and received answers. I consent to participate 

in the study.

Signature: ________________________________ Date: ________________________

Print Name: ______________________________ Position: _____________________

State: ____________________________
F–7

Promoting Student Success in Algebra I

Informed Consent: District Official Interview

Purpose

The Office of Elementary and Secondary Education (OESE) of the U.S. Department of Education (ED) 

requests clearance for the data collection for the Promoting Student Success in Algebra I (PSSA) study. 

The purpose of this study is to provide actionable information and greater insight into the knowledge 

and resources required to enable student success in mathematics between grades 6 through 9, with an 

emphasis on helping all students complete Algebra I by the end of the ninth grade. To this end, the 

evaluation will employ multiple data collection strategies.

To assist with the evaluation, we are asking district officials to participate in interviews. You will be 

interviewed about best practices for improving student success in mathematics and Algebra I, in 

particular. The interviews are designed to last no more than one hour.

Risks and Discomfort

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

Benefits

Your participation in the evaluation will contribute to an understanding of how state and local education 

agencies can work to improve student outcomes in Algebra I.

Confidentiality

We will treat the information that you supply in a confidential manner. Only selected research staff will 

have access to data. We will NOT present results in any way that would permit them to be identified 

with you or any other specific individual. No personally identifiable information, such as name or district 

affiliation, will be disclosed to anyone outside the project.

More Information

If you would like more information about this study, you may contact the Project Director, Kirk Walters, 

at the American Institutes for Research at 202-403-5838 or at kwalters@air.org. For questions regarding 

your rights as a subject participating in this research, please contact the Institutional Review Board (IRB) 

at IRBChair@air.org or toll free at 1–800–634–0797.

Informed Consent

I have read the above information. I have asked questions and received answers. I consent to participate 

in the study.

Signature: ________________________________ Date: ________________________

Print Name: ______________________________ Position: _____________________

District: ____________________________
F–8

Promoting Student Success in Algebra I

Informed Consent: Department Chair/Teacher Leader Interview

Purpose

The Office of Elementary and Secondary Education (OESE) of the U.S. Department of Education (ED) 

requests clearance for the data collection for the Promoting Student Success in Algebra I (PSSA) study. 

The purpose of this study is to provide actionable information and greater insight into the knowledge 

and resources required to enable student success in mathematics between grades 6 through 9, with an 

emphasis on helping all students complete Algebra I by the end of the ninth grade. To this end, the 

evaluation will employ multiple data collection strategies.

To assist with the evaluation, we are asking Department Chairs and Teacher Leaders to participate in 

interviews. You will be interviewed about best practices for improving student success in mathematics 

and Algebra I, in particular. The interviews are designed to last no more than one hour.

Risks and Discomfort

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

Benefits

Your participation in the evaluation will contribute to an understanding of how state and local education 

agencies can work to improve student outcomes in Algebra I.

Confidentiality

We will treat the information that you supply in a confidential manner. Only selected research staff will 

have access to data. We will NOT present results in any way that would permit them to be identified 

with you or any other specific individual. No personally identifiable information, such as name or district 

affiliation, will be disclosed to anyone outside the project.

More Information

If you would like more information about this study, you may contact the Project Director, Kirk Walters, 

at the American Institutes for Research at 202-403-5838 or at kwalters@air.org. For questions regarding 

your rights as a subject participating in this research, please contact the Institutional Review Board (IRB) 

at IRBChair@air.org or toll free at 1–800–634–0797.

Informed Consent

I have read the above information. I have asked questions and received answers. I consent to participate 

in the study.

Signature: ________________________________ Date: ________________________

Print Name: ______________________________ Position: _____________________

District/School: ____________________________
F–9

Promoting Student Success in Algebra I

Informed Consent: Professional Development Provider Interview

Purpose

The Office of Elementary and Secondary Education (OESE) of the U.S. Department of Education (ED) 

requests clearance for the data collection for the Promoting Student Success in Algebra I (PSSA) study. 

The purpose of this study is to provide actionable information and greater insight into the knowledge 

and resources required to enable student success in mathematics between grades 6 through 9, with an 

emphasis on helping all students complete Algebra I by the end of the ninth grade. To this end, the 

evaluation will employ multiple data collection strategies.

To assist with the evaluation, we are asking professional development providers to participate in 

interviews. You will be interviewed about best practices for improving student success in mathematics 

and Algebra I, in particular. The interviews are designed to last no more than one hour.

Risks and Discomfort

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

Benefits

Your participation in the evaluation will contribute to an understanding of how state and local education 

agencies can work to improve student outcomes in Algebra I.

Confidentiality

We will treat the information that you supply in a confidential manner. Only selected research staff will 

have access to data. We will NOT present results in any way that would permit them to be identified 

with you or any other specific individual. No personally identifiable information, such as name or 

district/school affiliation, will be disclosed to anyone outside the project.

More Information

If you would like more information about this study, you may contact the Project Director, Kirk Walters, 

at the American Institutes for Research at 202-403-5838 or at kwalters@air.org. For questions regarding 

your rights as a subject participating in this research, please contact the Institutional Review Board (IRB) 

at IRBChair@air.org or toll free at 1–800–634–0797.

Informed Consent

I have read the above information. I have asked questions and received answers. I consent to participate 

in the study.

Signature: ________________________________ Date: ________________________

Print Name: ______________________________ Position: _____________________

District/School: ____________________________