PARENT/GUARDIAN CONSENT FORM #1
Dear <Parent/Guardian>,
You and your child, ______, are invited to participate in a research study being conducted by myself, Hannah Mia DeBuuk, a Master’s degree student in the xxx program at the Minnesota State University, under the supervision of Dr. Warren T. DeKarr. The purpose of this project is to increase the effectiveness of behavior support plans written and implemented by school staff. School staff members have identified your child as a possible participant in this study because they believe that he/she may benefit from this project. Your participation in this study, however, is totally voluntary.
If you agree for your child to participate, I will work with your child and your child’s teacher to develop and implement behavioral supports. There will be 3phases to this process. First, I will interview your child’s regular classroom teacher to gather information about son or daughter’s strengths and challenges in the classroom, including information about his or her problem behaviors and academic performance. I will also speak with your child so that he or she knows what we will be doing and what to expect. This meeting should take no longer than 15-20 minutes. This interview information will be used to help build appropriate supports.
Second, I will determine the conditions that are most directly affecting your child’s problem behavior. I will do this by changing some conditions in the classroom, such as the amount of attention your child is receiving and/or the difficulty of the classroom work he or she is expected to complete, and observing your child’s behavior. During this phase, your child will participate in three conditions. One condition that is likely to lead to problem behavior and two conditions that shouldn’t lead to problem behavior. This part of the study will take about 30 minutes per day and continue for 1 to 3 weeks.
Lastly, I will develop and test behavioral supports for your child based on the information gathered in the interview and classroom assessment. Two interventions will be tested: one that should improve your child’s behavior and one that probably won’t improve your child’s behavior. Each intervention will be tested on a rotating basis in your child’s regular classroom. The interventions will be implemented for about 20-30 minutes at a time. The study will end with your child participating in the intervention that proved to be most effective for him or her. These interventions will be similar to treatments used regularly in classrooms, such as reward systems or time out. If you have any questions about possible interventions, please contact Dr. DeKarr or H. DeBuuk
During the second and third phases of this study, graduate students from the xxx graduate program and specially trained undergraduate students from the Department of xxx at Minnesota State University will serve as observers in your child’s classroom. I will work with them to ensure that they are properly trained in all of the procedures of this study.
Potential Risks to Your Child
We want the process of participating in this study to be enjoyable and helpful for your child. It is, however, possible that the attention directed toward him/her could cause psychological discomfort and that some tasks he/she engages in will lead to more problem behaviors or discomfort. To minimize the possibility of this happening, every attempt will be made to ensure that the conditions in the study closely resemble the natural conditions in your child’s classroom. Also, during all interactions with your child, your child and the classroom teacher will be able to tell me if they want me to stop the study for the day for any reason. If this occurs, I will meet with your child and his/her teacher to talk about what happened and establish a plan to ensure that similar situations will not recur.
If your child has become physically aggressive at times when he or she is frustrated or upset, there is a chance this sort of aggression will occur during our study. In that event, your child will have a slight risk of being injured. We will be relying on the school’s resources should any injuries occur, and you may wish to consider not participating if you believe that you child might hurt him or herself as well as others in the class. If aggression has been a problem with your child, our research is unlikely to make the situation worse, and we will do what we can to reduce the risk of more aggression. If you are unsure about participating for this reason, please contact either Dr. DeKarr or H. DeBuuk before making a decision.
It is also possible that other children in the class will notice that your child is being treated differently. There is a possibility that this could lead to stigmatization. In order to minimize the likelihood that this will happen, I and the other observers will attempt to focus as little attention on him/her as possible. If other children in the class ask what we are doing, we will tell them that we are learning more about the best way to teach elementary students. Should the other children realize that we are observing your son/daughter specifically, we will tell them that your child has agreed to help us with our study on the way things work in the school classroom. Also, your child’s name will not be included on any of the records we keep. We will, instead, use a made-up name to represent your child’s name on the record forms.
Benefits to Your Child
This study will result in the development and implementation of a behavioral intervention that should decrease your child’s problem behavior and increase his/her amount of time engaged in academic tasks. This information will be made available to your child’s teacher and he/she will be encouraged to continue using the intervention after the study has ended. Based on a review of the professional literature, it is anticipated that your child’s decrease in problem behavior could result in increased social opportunities and that the increase in the amount of time your child is engaged in academic tasks could improve his/her opportunities to learn.
The fact that your child is participating in our study will not be revealed to anyone in the classroom other than the teacher. Your child’s name will not be used in any reports. You and your child are free to stop participating in the study at any time by informing either Dr. DeKarr or H. DeBuuk by telephone, e-mail, or in writing. Ending your participation (or choosing not to participate) will not affect your relationship or your child’s relationship with his/her school or Minnesota State University.
If you have any questions, please feel free to contact me, Hannah DeBuuk, via email at or via phone at (507) 389-xxxx. You may also contact my advisor Dr. DeKarr via email at or via phone at (507) 389-xxx. If you have any questions about your rights as a participant, please contact Dr. Anne Blackhurst, administrator of the Institutional Review Board at (507) 389-2321.
Enclosed is a copy of this letter for you to keep. If you want your child to participate in our study, please complete the section below on one copy of this letter and return the signed copy in the addressed and stamped envelope provided. If you have any questions or would like anything clarified, please wait to sign and return this letter until you have spoken with me or Dr. DeKarr. Your signature indicates that you have read and understand the information above, that you willingly agree to participate, that you may withdraw at any time and discontinue participation without penalty, that you will receive a copy of this form, and that you are not waiving any legal claims, rights, or remedies. Thank you so much for your consideration.
Name of Parent/Legal Guardian (please print) ______
Print Child’s Name ______
Signature of Parent/Legal Guardian ______Date ______
It may be helpful for us to review your child’s school file. Please initial here if you are willing to allow research personnel access to this file. Initial: ______