Application for the Use of Ecls-K Assessments, Socioemotional Rating Scales, And/Or Item-Level

APPLICATION FOR THE USE OF ECLS-K ASSESSMENTS, SOCIOEMOTIONAL RATING SCALES, AND/OR ITEM-LEVEL DATA

Part I: General Information

1. Applicant

1. Name:______

1. Address:______

______

______

1. Organizational Affiliation:

______

______

______

1. Phone:______

1. Email Address:______

Please complete sections B, C, D, and E as applicable for your research. If a section is not applicable, please leave the section blank. Information should be provided in at least one of sections B through E.

1. Cognitive test instruments requested: Please check the ECLS-Kassessments you are requestingto administer in your own study.

1. Cognitive assessment item-level data requested: Please check the ECLS-K item-level data you are requesting.

1. Socioemotional rating scales requested: Please check the ECLS-K Social Rating Scale (SRS)questionnaire items you are requesting to administer in your own study.

1. Socioemotional rating scales item-level data requested: Please check the ECLS-K Social Rating Scale item-level data you are requesting.

1. Intended Use of Instruments. Indicate how the assessments or item-level data will be used.

1. To conduct assessments of students? YES ______NO ______

1. If Yes,

1. Number involved: ______schools, ______students
2. Assessment schedule: Begin ______End ______
3. Description of study: Please describe below or attach description.

1. For secondary analysis? YES ______NO ______

1. If Yes, describe the planned analysis belowor attach description. If requesting item-level data, clearly indicate why the publicly-available data is not sufficient for your research purposes.

1. For other uses?YES ______NO ______

1. If Yes, indicate the intended use belowor attach description. If requesting item-level data, clearly indicate why the publicly-available data is not sufficient for your research purposes.

Part II: Item Security

1. Person(s) with access to secured–use assessments, instruments, or item-level data.

Please provide a complete list of all persons who will have access to secured-use items. (Do not list students who are being assessed.)

NamePositionOrganizational Affiliation

Example:

John DoeTeacherJefferson H.S., Alexandria, VA

Jane SmithSecretaryJefferson H.S., Alexandria, VA

1. Security for instruments storage. Indicate where the assessments, instruments, or item-level data will be stored and what security procedures will be used to prevent disclosure.

1. When will your work with the secured-use assessments, instruments, or item-level data be completed?

1