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.

Assessment Year / Assessment
Reading / Math / General Knowledge/
Science
Kindergarten -
First Grade
Third Grade
Fifth Grade
Eighth Grade
  1. Cognitive assessment item-level data requested: Please check the ECLS-K item-level data you are requesting.

Assessment Year / Item-Level Data
Reading / Math / General Knowledge/
Science
Kindergarten -
First Grade
Third Grade
Fifth Grade
Eighth Grade
  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.

Assessment Year / SRS Questionnaire Items
Parent-Report / Teacher-Report
Kindergarten -
First Grade (parent, teacher)
Third Grade (teacher)
Fifth Grade (teacher)
  1. Socioemotional rating scales item-level data requested: Please check the ECLS-K Social Rating Scale item-level data you are requesting.

Assessment Year / SRS Item-Level Data
Parent-Report / Teacher-Report
Kindergarten -
First Grade (parent, teacher)
Third Grade (teacher)
Fifth Grade (teacher)
  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?

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