6. Sample Consent and Research Study Form (UCSD)

This is an example from UCSD of a consent form foran interpreter, classroom aide, or other adult participating in the video taping of the Teaching Event. This example asks permission for both Teaching Event scoring purposes and for research use of the videotape in testing a digitized Teaching Portfolio system.

IRB: 040827S

University of California, San Diego

Consent to Act as a Research Subject

PACT Electronic Portfolio project

Randall Souviney, Ph.D at the University of California, San Diego is conducting research to learn if a kind of software called electronic portfolios are a useful tool in teacher education and teacher credentialing. You have been asked to take part in this study because you are an interpreter, classroom aide, or other adult working in the classroom of a credential candidate from Education Studies at the University of California, San Diego, which is a PACT institution. Current participants in the PACT Electronic Portfolio project include the eight campuses of the University of California, Stanford University, University of Southern California, Mills College, San Jose State University, San Diego State University and several other campuses of the California State University.

We are asking your permission to use these video recordings and classroom teaching materials for research and educational purposes. Although the videotapes involve both the student teacher and various students, the primary focus is the student teacher’s instruction, not on the performance of the students, interpreters, classroom aide or other adult working in the classroom. In the course of taping, you may appear on the videotape but the videotape will not be used as an evaluation of your skills as an interpreter or classroom assistant. Your name will not appear on any materials that are submitted. We wish to learn if a new kind of electronic portfolio software (ePortfolio, weTeach, and DIVER) makes it easier to use video recordings when making credentialing decisions, and whether video recordings are useful tools for training teachers at schools of education in the PACT universities. This technology allows a user to precisely focus on classroom events captured in a video recording and to attach text annotations to those events. Electronic portfolios facilitate the production and distribution, via the Web, of annotated videos containing samples of concrete teacher performances corresponding to abstract categories such as “developing mathematical reasoning.” The web-accessible electronic portfolio allows users to engage in discussionof annotated clips, allowing scorers to comment on whether a particular interpretation is actually appropriate. We hypothesize that this use of an electronic portfolios is likely to promote a more uniform level of expertise and evaluation among scorers of credential candidates than is generally possible with assessment based on traditional paper portfolios and VHS video records.

Video recordings will be used to build a database of classroom events, which will be analyzed for content, evaluation rubrics, commonality across campuses, and potential for inclusion in a UCSystemwide teaching performance assessment system being developed by the participating institutions. The student teacher’s classroom teaching materials may also be digitized and included in your electronic portfolio. In addition to studying the effectiveness of the software, we will use the annotated clips for professional development at the schools of education participating in the PACT Electronic Portfolio project. The information you provide may also be included in research reports, articles published as a result of this study, and in presentations to interested parties.

Should you choose to participate, video recordings of the UCSD Education Studies student teacher’s teaching practice will be made available to members of the PACT Electronic Portfolio project via the World Wide Web. Access to the recordings will be password controlled and recordings will be stored in a secure server. Those with access to the secure website will include teacher education faculty at PACT institutions, PACT researchers, and portfolio scorers.You will not be personally identified in any use of the video recordings. Video recordings and classroom teaching materials will be assigned a unique identifier and that identifier will be used on the secure website. However, even with a unique identifier it is reasonable to expect that you will be recognizable in your PACT electronic portfolio by students and faculty within your own school.

IRB: 040827S

There may or may not be any direct benefit to you from this research. The investigator(s), however, may learn more about ways of improving the teacher credentialing process and the education of new teachers.

Although we foresee no risk to you as the result of participation in this research, there is always a small risk that confidentiality might be compromised.

Participation in research is entirely voluntary. You may refuse to participate or withdraw at any time without penalty. There are no penalties to you if you decide not to participate. Your decision about whether or not to participate will not affect your relationship with your Education Studies Program or your K-12 school.

Research records will be kept confidential to the extent allowed by law and completed video recordings may become a permanent part of a secure, password-protected library maintained by the researchers for use in schools of education at the twelve universities participating in the PACT Electronic Portfolio project.

Randall Souviney or one of his colleagues has explained this study to you and answered your questions. If you have other questions or research-related problems, you may reach Randall Souviney at or 858-534-1682.

If you have questions about your rights as a research subject, or wish to report a research-related problem, you may call the UCSD Human Research Protections Program at (858) 455-5050 or view your rights by going to and selecting “Experimental Subject's Bill of Rights.”

I DO give permission to you to video record in my classroom and use video recordings of my student teacher’s classroom practice and teaching materials for the purposes described above.

I DO NOT give permission to you to video record in my classroom and use video recordings of my student teacher’s classroom practice and teaching materials for the purposes described above.

Signature of Cooperating Teacher: ______Date: ______

Name: ______(Please Print)

Last First M.I.

Signature of Witness: ______Date: ______

Name: ______(Please Print)

Last First M.I

(Document 16.12 – To be completed by the interpreter, classroom aide, or other adult participating in the video taping of the UCSD Education Studies credential candidate teaching practice.)

Source: UCSD

Created: Fall 2006