TEACHER CONSENT FORM/STUDENT INVESTIGATOR/RECRUITMENT LETTER
Dear <Teacher>
My name is Jane Doe. I am a graduate student in the xxx program at Minnesota State University,
Mankato. I would like to conduct research in your school under the supervision of my advisor from
the Department of xxx, Dr. John Smith. The purpose of my study is to develop a model for
assessment and intervention for students with problem behaviors in the classroom.
If you agree to participate, I would like to interview you to understand the problem behaviors of
your student. This interview will take about 30 minutes. The results will be used to help me develop
a behavior support plan for the participating student. Specifically, 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 ask that you
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 common 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. 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.
It is possible that there are other interventions that could help improve your students’ behaviors.
Your participation is totally voluntary. If at any time during the interview, intervention, or
assessment you decide that you would prefer not to answer a question or discontinue the study
completely you are free to do so. Discontinuing the study will not affect your relationship with
Minnesota State University, Mankato. You can stop participating by telling the researcher you no
longer want to be in the study.
A possible benefit of this research is the reduction of your child’s problem behaviors. By the end of
the study, we hope to decrease greatly or even eliminate the problem behaviors in one or more of
your students. We will also provide you with all the information you will need to continue the
treatment should you choose to.
Initial:
This study also may benefit society by demonstrating the effectiveness of such classroom
interventions for use with other children. 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. 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.
All your answers will be kept confidential. 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
participant’s names will not be on the data forms either. Pseudonyms will be used instead of
student participant’s names. All consent forms will be kept in a locked filling cabinet in a secured
office at Minnesota State University by Dr. Smith.
If you have any questions please feel free to contact me, Jane Doe, at jane.doe@mnsu.edu or (507)
389-xxxx. You may also contact my advisor, Dr. Smith, at john.smith@mnsu.edu or (507) 389-xxxx.
If you have any questions about the rights of research participants please contact Dr. Barry Ries,
Administrator of the Institutional Review Board, at (507) 389-1242 or barry.ries@mnsu.edu.
Enclosed is a copy of this letter for you to keep. If you are willing to participate in our study please
initial the first page and sign this page of this letter and return it to me. Your signature indicates
that you have read and understand the information above and willingly agree to participate Thank
you for your consideration.
Your Name (printed) ________________________
Your Signature _____________________________ Date _____________
MSU IRBNet LOG #
Date of MSU IRB approval: