TEACHER CONSENT FORM #1
Dear <Teacher>,
My name is Hannah Mia DeBuuk. I am a graduate student in the xxx program at
Minnesota State University. I would like to conduct research in your school under the
supervision of my advisor from the Department of xxx, Dr. Warren T. DeKarr. The
purpose of my study is to develop a model for assessment and intervention for students
with problem behaviors in the classroom. By the end of the study, we hope to greatly
decrease or even eliminate the problem behaviors of one or more of your students. We
will also provide you with all the information you will need to continue the treatment
should you need it again. I would like your help in collecting information about a child
(or children) in your classroom whose parents have agreed to let them participate in this
project. Your participation, however, is totally voluntary.
If you agree to participate, I would like to interview you in order to understand the
problem behaviors of your student. This interview would take about 30 minutes to
complete and the results would be used to help me develop a behavior support plan for
the participating student. If at any time during the interview you decide that you would
prefer not to answer a question or discontinue the interview completely, you are free to
do so and discontinuation will not affect your relationship with your school, school
district, or with Minnesota State University.
After the interview, I would like to work with you and the participating
student/students in your class for about six to eight weeks. Sessions will last about 30
minutes and will take place about 3-4 times per week. I will need your help to complete
the assessments and interventions, but both components will easily be incorporated into
your class structure. When I am in your classroom, I will be asking you to engage the
student in non-disruptive tasks. Only your requests to the student will change. You
should respond to the child’s behavior in the way that you would usually. For example,
we may ask you to provide the student with attention and then remove all attention for
about 10 minutes. This will allow us to see if the child’s behaviors are driven by the
desire for attention. We will use three commonly academic situations like this per
student. One of these task situations will temporarily increase the student’s problem
behaviors, but the increase should revert to normal levels once the assessment
session is finished.
Some children occasionally become physically aggressive when they are upset or
frustrated. You or the parents of the child participant may wish to reconsider
participation in the study should physical aggression occur, and we will respect and
uphold your right to end your involvement in our study at any time. Our procedures
should not elicit aggressive behaviors that have not been witnessed before. We will
acquaint ourselves with your policies and procedures for dealing with student aggression
before beginning any observations. Should injuries occur, we will rely on the school’s
resources for treatment.
During the intervention phase, we will recommend two school-appropriate
interventions and show you how to implement both programs. One of them should
decrease your student’s problem behaviors while the other is unlikely to change anything.
Neither of the interventions should increase your student’s problem behaviors. An
additional student from Minnesota State University, Mankato will frequently accompany
me to collect observational data on the participating student. You are free to request that
our involvement in the classroom be discontinued at any time, again with no penalty to
you or the participating student.
The only identified risk associated with your involvement in this study is the
possibility that your participation could be discovered by other people, including faculty
and staff in your school. To minimize this risk, your name will not be recorded on any of
the materials in this study. Instead, your identity will be recorded as the “Teacher of
participant ____.” Student participants’ names will not be on the data forms, either.
Pseudonyms will be used in lieu of student participants’ names. Thus, your identity and
participation in this study should not be revealed to anybody.
If you have any questions, please feel free to contact me, Hannah DeBuuk, via
email at hannah.debuuk@mnsu.edu or via phone at (507) 389-xxxx. You may also
contact my advisor Dr. DeKarr via email at warren.dekarr@mnsu.edu or via phone at
(507) 389-xxxx. 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 are willing to participate
in our study, please complete the section below on one copy of this letter and return it to
me. 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. If you have any questions
or would like us to clarify any point, please ask us to address your concerns before you
sign this form. Thank you for your consideration.
Your Name (printed) ________________________
Your Signature _____________________________
Date _____________