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Appendix A

Approved Teacher Consent and Demographic Form
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INFORMED CONSENT TO PARTICIPATE IN THE RESEARCH STUDY

Introduction

This project is intended to evaluate a mathematics professional development program (PD) for grade 4 

teachers called Developing Mathematical Ideas (DMI). The research study will examine outcomes for 

both teachers and the students.

There is currently little scientific evidence that math professional development provided to teachers 

actually helps to improve student achievement. This study hopes to fill in this important gap in our 

scientific knowledge of an important and wide-spread educational practice.

This study is a randomized controlled trial, where schools will be randomly (like the flip of a coin)

assigned to receive DMI or to receive math PD as typically provided in the district. This type of 

experiment provides the strongest evidence of whether PD delivered to teachers may have an impact on 

student achievement. You cannot choose which education type your study school will receive. 

Study Funding and Personnel

This study is funded by the Regional Educational Laboratory Southeast at Florida State University 

through a grant from the U.S. Department of Education and will be conducted by the employees and 

subcontractors of REL Southeast. 

Study Length and Participants

Fourth grade teachers in 84 schools in 4-5 districts in South Carolina and in 4-5 districts in Georgia 

will participate in the study which will last about 1 year.

Confidentiality

Information collected for this study comes under the confidentiality and data protection requirements of 

the Institute of Education Sciences (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 

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

district, school, or individual. We will not provide information that identifies you, your district or your 

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

Total confidentiality cannot be guaranteed. No information that identifies any study participant will be 

released. Information from participating institutions and respondents will be presented at aggregate levels 

in reports. Information on respondents will be linked to their institution but not to any individually 

identifiable information. No individually identifiable information will be maintained by the study team

after approval of the final report. If the study results are presented at meetings or printed in publications, 

your name will not be used.

Staff working on the project have signed confidentiality pledges and been screened for data security 

through the U.S. Department of Education e-qip system. Only persons conducting this study and 

maintaining and monitoring its records will have access to the records collected that contain individually 

identifying information.

TID# _____________

(for study staff only)
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The Institutional Review Board (IRB), IntegReview, and accrediting agencies may inspect and copy your 

records, which may have your name on them. Therefore, total confidentiality cannot be guaranteed.

Benefits

If you choose to participate in this study and your school is placed in the experimental condition, you will 

be exposed to the DMI professional development, which may improve your knowledge of teaching math 

and your ability to teach mathematics. Your participation in the study will assist in evaluating the 

effectiveness of the DMI professional development program. Information learned from this study may 

assist in the improved design of instruction for future mathematics professional development.

Alternatives to Participating in the Study 

Since this study is for research only, the only other choice would be not to be in the study. 

Costs

There will be no added costs for the curriculum and education and no additional costs for participation in 

this study. 

Volunteering to Participate in this Study

Participation of teachers in the study is voluntary and not a condition of employment. You do not have to 

participate in this study, and you can change your mind at any time. There will not be any penalty or loss 

of benefits to you if you decide not to participate in this study or to leave this study. If you leave the 

study early, you will be paid for each form/activity completed at the time of your withdrawal. If you want 

to stop participating in the study, tell the study staff and he they will terminate your participation in the 

study. If you leave the study, no more information about you will be collected for this study. However, 

all of the information you gave us before you left the study will still be used for research purposes only. 

The information we collect, including student scores on the math test, will not be used to evaluate your 

performance.

Random Assignment and Time Commitment 

This is a random assignment study, the gold standard of research designs. However this design is 

vulnerable to potential bias in the findings if participants know ahead of time what experimental condition 

they are in. This is because people may make different decisions about their participation based on their

knowledge of which group they were assigned to, violating the intent that group membership be random 

and not determined by other factors.

Therefore we are asking that you commit to participation in the study before you know the experimental 

condition your school will be assigned to. This is critical for the scientific validity of the results. The 

table below lays out the possible time commitment you will be agreeing to in advance, with the actual 

amount to be determined later by random assignment of your school.

Ultimately each school participating from your district will be paired with a similar school in the district. 

Each school in the pair will have a 50% chance of being assigned to receive DMI or the control condition. 

It is important that you completely understand the time commitments for both conditions in this study 

before agreeing to participate. You are committing to participate in whichever condition your school is 

assigned to.
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Time commitments for each condition in the study.

Participation Activities Time Commitment Condition

DMI Control

Consent & Demographic Form 12 minutes .2 hours .2 hours

Teacher Knowledge, Pre- & Post-Test

2 X 2 hours 

proctored on-site

(+ transit time)

4 hours 4 hours

DMI – Sessions 8 X 3 hour sessions

(≈ 24 hours) 24 hours

DMI – Homework 7 X 3 hours

(≈ 21 hours) 21 hours

A total of 8 release days from instruction will be granted for teachers in the DMI PD 

condition to attend sessions and complete homework assignments.

Monthly PD Survey 9 X 12 minutes 

online 1.8 hours 1.8 hours

Allowing student group to take post-test 45 minutes

during class time .75 hours .75 hours

TOTAL Estimated participation time ≈ 52 hours ≈ 7 hours

Legal Rights

You will not lose any of your legal rights by signing this consent form.

Public Burden Statement

According to the Paperwork Reduction Act of 1995, no persons are required to respond to a collection of 

information unless such collection displays a valid OMB control number. Public reporting burden for this 

collection of information is estimated to average 12 minutes, including time for reviewing instructions, 

searching existing data sources, gathering and maintaining the data needed, and completing and reviewing 

the collection of information. The obligation to respond to this collection is voluntary. Confidentiality is 

not guaranteed. Send comments regarding the burden estimate or any other aspect of this collection of 

information, including suggestions for reducing this burden, to the U.S. Department of Education, 400 

Maryland Ave., SW, Washington, DC 20202-4536 or email ICDocketMgr@ed.gov and reference the 

OMB Control Number 1850-xxxx.
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Consent for Participation

I, _______________________________________, a 4th grade teacher at 

________________________________________ hereby agree to participate in the Fractions PD study, 

conducted by the Regional Educational Laboratory Southeast at Florida State University, and its 

subcontractor Instructional Research Group.

Remuneration:

I understand I will be paid $150.00 for completing the forms and activities in the table on the previous 

page. This represents a typical rate paid in the state for time outside of the regular teacher contract with 

the district. Regardless of how much time is actually spent completing measures and activities, I 

acknowledge that these estimates were made in good faith by the research team and represent the 

remuneration I will be paid for participation, if I complete all activities as scheduled. If I leave the study 

early, I will be paid for each hour completed at the time of my withdrawal.

I understand that if my school is randomly assigned to participate in the PD condition, I will attend eight 

3-hour DMI training sessions and will be required to complete subsequent homework activities. A total of 

8 release days from instruction will be granted for teachers in the PD condition to attend sessions and 

complete homework assignments.

I further understand that my participation will continue only as long as it is mutually agreeable and 

that I can end my participation at any time. Final remuneration would be based on the activities 

completed. I agree that study staff may contact me to follow-up on activities and for scheduling purposes.

I was offered a copy of this consent form for my records. If I have further questions about this study or 

my rights, I can contact the study manager, Christopher Tran at 714-826-9600 or ctran@inresg.org. 

If I do not want to talk to the investigators or study staff, if I have concerns or complaints about the 

research, or to ask questions about my rights as a study subject I may contact IntegReview. IntegReview’s 

policy indicates that all concerns/complaints are to be submitted in writing for review at a convened IRB 

meeting to:

 Mailing Address: OR Email Address:

Chairperson

IntegReview

3001 S. Lamar Blvd., Suite 210

Austin, Texas 78704

integreview@integreview.com

If I am unable to provide my concerns/complaints in writing or if this is an emergency situation regarding

subject safety, contact their office at:

512-326-3001 or 

toll free at 1-877-562-1589

between 8 a.m. and 5 p.m. Central Time 
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IntegReview has approved the information in this consent form and has given approval for the 

investigators to do the study. This does not mean IntegReview has approved my being in the study. I

must consider the information in this consent form for myself and decide if I want to be in this study.

__________________________________ ________________________________________

Teacher’s Signature Date

Name: __________________________________ (Please print)

Address: __________________________________ (Street)

__________________________________ (City, State, ZIP)

Phone: (__ __ __) __ __ __ - __ __ __ __

Email: __________________@___________.______
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Teacher Demographic Questionnaire

This demographic questionnaire is to be completed at the same time as the consent form. 

Information collected for this study comes under the confidentiality and data protection requirements of 

the Institute of Education Sciences (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 

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

district, school, or individual. We will not provide information that identifies you, your district or your 

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

Name: _________________________________ School: _________________________________

Gender (Circle One): 

Male Female

Degrees (please list all completed, specifying major):

BA: __________________________________

MA: __________________________________

Post-MA: ______________________________

Other: ________________________________________________

Years of In-service Teaching (please enter whole years, rounded up):

Total Years of Classroom Teaching Experience ____

Total Years of 4th grade Classroom Teaching Experience ____

Total Years Teaching in Current School ____

Total Years Teaching Math in Middle/High School (Grades 6-12) ____
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Certifications (please check all that apply):

Elementary ____ 

Middle School ____

Mathematics ____

Math Specialist ____

Reading Specialist ____

Bilingual Education ____

Special Education ____

Speech/Language Specialist ____

Alternative Certification ____

Administrative ____

Other: __________________________________

THANK YOU FOR COMPLETING THIS FORM!

Public Burden Statement

According to the Paperwork Reduction Act of 1995, no persons are required to respond to a collection of 

information unless such collection displays a valid OMB control number. Public reporting burden for this 

collection of information is estimated to average 12 minutes, including time for reviewing instructions, 

searching existing data sources, gathering and maintaining the data needed, and completing and reviewing 

the collection of information. The obligation to respond to this collection is voluntary. Confidentiality is 

not guaranteed. Send comments regarding the burden estimate or any other aspect of this collection of 

information, including suggestions for reducing this burden, to the U.S. Department of Education, 400 

Maryland Ave., SW, Washington, DC 20202-4536 or email ICDocketMgr@ed.gov and reference the 

OMB Control Number 1850-xxxx.