Informed Consent Form

Action Research

Informed Consent Form (Non-implementation)

Information

Course: EDU671 Fundamentals of Educational Research and EDU675: Change Leadership for the Differentiated Educational Environment

Researcher Name: ________________Jeffrey A. Trent______________Researcher Email: __[email protected]__________________

Researcher Phone: _3183825140_________________ Program of enrollment (MAED/MATLT) __MATLT________

Location of Proposed Intervention/Innovation: _________________N/A_______________

This form serves two purposes; first, to acknowledge approval from the building principal or company supervisor for the researcher to conduct the proposed action research and second, to inform participants and/or parents/guardians of minor participants of the intentions of your study.

Student-researchers must submit this form if the proposed study involves any person(s) other than themselves for which a planned intervention or innovation will occur. Students using this form within a school setting or other place of employment must be a current employee at the site to seek permission to conduct action research at this location. A separate form must be provided to and signed by each parent or guardian of all minor (school-aged) children and/or adult participant involved in the study. Each signed form will be reviewed by the student-researcher’s employer as verification of participant acknowledgment.

Ashford instructors of EDU671 will store a back-up copy of this completed form in a secured drive, although it is the student researcher’s responsibility to save, store, and submit to their instructors of both EDU671 and EDU675 as required.

Purpose: The purpose of this research is to determine the factors that affects students in the classroom which becomes distractions and cause them to be placed in a Alternative Room setting. (ISS Room) Through this research what can be done to assist them in regaining the structure and stability that they need in the classroom.

Participation: You will be asked to [list what the participant is asked to do e.g. provide demographic information, be observed in the classroom setting, sharing opinions and attitudes, or participating in measures of academic achievement.

Risks: There are no foreseeable risks to you as the subject.

Personal Benefits: There will be no personal benefits to you from your participation in this research. However, the results of the research are intended to contribute to EDU671 Fundamentals of Educational Research and EDU675 Change Leadership and Differentiated Instructional Environment class at Ashford University.

Time: Your participation in the action research study will take approximately [N/A]. The duration of this research project is [N/A].

Voluntariness: Your participation in this research is strictly voluntary. You may refuse to participate at all, or choose to stop your participation at any point in the research without fear of penalty or negative consequence.

Confidentiality: The information/data you provide for this research will be treated confidentially, and all raw data will be kept in a secured file by the researcher. Personally identifiable information will not be shared.

Review of Research: You also have the right to review the results of the research if you wish to do so. A copy of the results may be obtained by contacting the researcher: [N/A]

Required Signatures

Supervisor Consent

I, (print full name) ______N/A___________ have communicated with the researcher during the planning stages of their proposed action research study and approve of their proposed study including the pending intervention/innovation to be conducted during their enrollment in the subsequent course; EDU675. My signature as the supervisor indicates the student conducting this proposed action research is an employee under my supervision. I further acknowledge receipt and viewing of all signed and returned Informed Consent forms completed by participants and/or adults of minor children participating in said action research intervention/innovation.

Name of Supervisor (please print)______N/A_________________ Position/Title:________N/A__________________ Phone:____________N/A______________ Email:____________N/A____________

Signature:___________N/A___________________________ Date:____N/A_________

Student-Researcher Acknowledgement

To be completed by the Ashford, MAED student

As the student-researcher of EDU671, I (your name) _________________ acknowledge and accept my responsibility to attain all signatures and submit the Informed Consent form to my instructor by Week of EDU671 and again during Week One of EDU675. I understand I will not move on to EDU675 and implement my proposed intervention/innovation unless the Informed Consent form is completed and submitted on time.

Please clearly state why you do not need to obtain informed consent from a supervisor and participants

Because of the nature of the research at hand and the participants that are involved signatures aren’t required of this particular practice. The students will not be subject to any type study that will present any personal information. Because of this they will be protected and will not need any type of consent form to complete the research study. Also Louisiana school systems don’t require consent forms for this type of anonymous research studies. ________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________.

Participant Consent

To be completed by the parent/guardian of minor participants and/or adult participants

I, (print full name) ____________N/A______________, have read and understand the preceding information explaining the purpose of this research and my rights and responsibilities as a subject and/or parent/guardian of a minor participant. My signature below designates my consent to participate in this research, according to the terms and conditions listed above.

Participant/Parent/Guardian Signature:__________N/A_______________________ Date: _________N/A_______