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

Name of Primary Researcher

LastFirst

Mailing Address

Street

CityStateZip

Preferred Email

Phone Numbers

CellphoneHomeWork

Current Employer

Job Title

Affiliated Institution

Name and Title of Advisor/Sponsor (if applicable)

Additional Researchers

Have you completed CITI training in the past 5 years? (Please attach proof of training completion)

⧠ YesDate of Completion: ______

⧠ No Date of Expected Completion: ______

Have you received IRB approval by your academic institution?(Please attach IRB approval letter)

⧠ YesInstitution: ______Date: ______

⧠ No

If your research involves direct contactwith students and teachers, you must undergo fingerprinting and background check. Have you been fingerprinted and background checked by Polk County Public Schools?

⧠ YesDate: ______

⧠ NoPlease 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.

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 thePolk County School District’s Strategic Plan?

Is your research study funded? Briefly describe funding sources (if applicable).

Listone to three high priority research questions and/or hypotheses for this project

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.

School Name
(If applicable) / Type of Research Activity / Time Required in Minutes
Observation or Delivery of Instruction / Conducting a Training / Administration of
Assessments / Surveys & Interviews / Other (Specify) / Students / Teacher / Parents / Guardians / School Administrators / Other (Specify)
e.g. Jefferson Elementary / X / X / 15 / 15 / 0 / 0 / 0

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:

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 / Grade Level(s) / How will you use this data in your study?
e.g. Student ScoresFSA Math / 2014-2015 / 6-8 / Math scores will be used as a posttest to determine student growth.

How many participants will be required?Fill-out the following chart with the number of participants required per grade level.

Participants / School Grade / Other / Total
K / 1 / 2 / 3 / 4 / 5 / 6 / 7 / 8 / 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

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 / Possible Risks / Mitigation Approaches
Students
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:

Activity / Date(s)
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:

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).

  1. A sample letter to parents/guardians requesting permission for student participation (if appropriate)
  2. A letter from principals/teachers granting permission to conduct research in their school/classroom (if appropriate)
  3. 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.

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