Polk County Public Schools
Office of Assessment, Accountability and Evaluation
1915 South Floral Avenue
Bartow, FL 33830
(863) 534-0780 / Fax (863) 534-0770
APPLICATION TO CONDUCT RESEARCH
PART 1. Applicant Information
Name of Primary Researcher
Last
First
Mailing Address
Street
City
State
Zip
Home
Work
Preferred Email
Phone Numbers
Cellphone
Current Employer
Job Title
Affiliated Institution
Name and Title of Advisor/Sponsor (if applicable)
Additional Researchers
PART 2. Protection of Human Subjects in Research
Have you completed CITI training in the past 5 years? (Please attach proof of training completion)
⧠ Yes
Date of Completion: _________________
⧠ No
Date of Expected Completion: ________________
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Have you received IRB approval by your academic institution? (Please attach IRB approval letter)
⧠ Yes
Institution: ____________________________ Date: _________________
⧠ No
If your research involves direct contact with students and teachers, you must undergo
fingerprinting and background check. Have you been fingerprinted and background checked by
Polk County Public Schools?
⧠ Yes
Date: ___________________
⧠ No
Please make an appointment at (863) 534-0414 or (863) 519-3672. The cost
is $93.85 and must be absorbed by the researcher or research sponsor.
⧠ Non-Applicable, I am a Polk County Public Schools employee.
PART 3. Research Study Information
Research Study Title:
Purpose of the Study (Briefly describe the reason for conducting this research project)
Short Topic of Study (6 words or less):
Specifically, how does this study align with the Polk County School District’s Strategic Plan?
Is your research study funded? Briefly describe funding sources (if applicable).
List one to three high priority research questions and/or hypotheses for this project



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Brief Description of Methodology
What estimated time is required of participants? Fill-out the following chart with the name of
the school (if applicable) where you will be conducting research, select the type of research activity,
and the amount of time required by participant type. An example has been provided.
X
15
0
0
Other (Specify)
School
Administrators
15
Teacher
Students
Other (Specify)
Surveys &
Interviews
Time Required in Minutes
Parents /
Guardians
e.g. Jefferson
Elementary
Administration
of
Assessments
(If applicable)
Conducting a
Training
School
Name
Observation or
Delivery of
Instruction
Type of Research Activity
0
X
Do you propose the use of existing instruction time?
⧠ Yes ⧠ No
If so, what procedures will you implement to make effective use of instructional time?
If not, when will the study to be carried out?
Specific data-gathering instrument(s) to be used (please attach copies) and description of
reliability and validity evidence to be obtained:
3
Is access to school records required?
⧠ Yes ⧠ No
What type of data are you requesting or collecting? Fill-out the following chart with the type of
data, school year, grade level(s), and a brief description of data usage. An example has been provided.
Type of Data
School
Year
2014-2015
e.g. Student Scores FSA Math
Grade
Level(s)
6-8
How will you use this data in your study?
Math scores will be used as a posttest to
determine student growth.
PART 4. Participants
How many participants will be required? Fill-out the following chart with the number of
participants required per grade level.
Participants
K
1
2
3
4
School Grade
5 6 7 8
Other Total
9
10
11
12
Students
Teachers
Parents/Guardians
School
Administrators
Other (Specify)
Total Participants
How will you protect the confidentiality and anonymity of participant responses? Fill-out the
following chart with specific security measures/protocols that you will implement.
Confidentiality of
Responses
Anonymity of Responses
(mandatory for student data)
Secure Storage of Data
Security
Measures
4
Are there possible psychological, emotional, and/or physical risks to participants? Fill-out
the following chart specifying the potential risk and mitigation approaches that will be
implemented.
Participant
Students
Possible Risks
Mitigation Approaches
Teachers
Parents/Guardians
School Administrators
Other (Specify)
Please state the nature of any benefit(s) to participants (school/student) that might result
during this study:
PART 5. Research Timeline
Activity
General Study Time Frames:
Proposed Start Date for Data Collection:
Proposed Completion Date for Data Collection
Estimated Date of Executive Summary Submission:
Estimated Date of Research Product Submission:
Date(s)
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PART 7. Considerations
Please Note: In addition to Research Review Board approval, parental consent and
principal permission must be obtained before beginning any research activity.
The following information must accompany the application and be assembled into three identical
packets:
1. The completed “Request for Research” form
2. A brief abstract, not exceeding 200 words.
3. A detailed research proposal (Review PCPS General Guidelines for more
information).
4. A sample letter to parents/guardians requesting permission for student
participation (if appropriate)
5. A letter from principals/teachers granting permission to conduct research in their
school/classroom (if appropriate)
6. Evidence of recent (within five years) human subjects research training. College and
university affiliated researchers must obtain approval of their proposed research by
their Institutional Review Board or similar committee. Evidence of approval must be
submitted before any data is collected.
I certify that the information provided to Polk County Public School’s Office of Assessment,
Accountability, and Evaluation is truthful to the best of my knowledge.
Signature of Primary Researcher: ____________________________________
Date: ________________
If completing research from a university or institution, please provide the following:
Signature of Sponsor: __________________________________________
Date: ________________
Title of Sponsor: ___________________________________________________________________________________
Mail completed form and proposal to:
Research Requests
Polk County Public Schools
Assessment, Accountability, & Evaluation
P.O. Box 391
Bartow, Florida 33830
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