Work & Academics

Appendix A: Parent Information and Consent Form

The student and parent questionnaires¹ will be conducted as interviews. As the primary language for most of the parents is Spanish, the interview will be conducted in Spanish unless requested otherwise. Students can decide whether they prefer being interviewed in Spanish or in English. The following verbal directions will be given and a signatory consent form (with the same instructions) will be completed by both the interviewer and the interviewee:

Dear Parent/Student,

Thank you for taking part in our survey. As always, our intent is to improve the offerings at the after-school program, and finding out more about you/your child will help better serve your child or meet your child’s learning needs. As such, we are implementing a short-term formal research of how to best educate children with emotional difficulties or learning disabilities.

The interview we are conducting today asks many personal questions—questions you may find difficult to answer. Please be assured that all your responses will be treated confidentially. Upon the completion of the research, we will create both a teacher’s handbook and a parent’s handbook which will indicate ways to best manage the problems we may face. The purpose of the handbooks is to provide generalized information to the respective parties. Your privacy is of utmost importance to us; at no point will personal or other identifiable information be used in these handbooks.

Before completing the interview and signing this consent form, please ask your interviewer any questions or concerns you may have. Upon the completion of the interview, you will be given a chance to add any additional insights you may have had during the interview process.

Thank you for your time and patience,

Sincerely,

[SIGNED]

I, [PARENT NAME], have received instructions about the following interview and its purpose and agree to take part in the research process.

[SIGNED], [DATED]

I, [INTERVIEWER NAME], have accurately described the research process and sufficiently answered additional questions to the above signed individual and promise to respect the individual’s privacy in completing the study.

[SIGNED], [DATED]

Appendix B: Sample Student Questionnaire/Interview

1. Are you able to do most of your schoolwork and homework completely?
2. What would make it easier for you to complete your work?
3. What would make it easier for you to cooperate with your classmates?
4. How much do you think your teacher knows about you? How much is that picture actually like you?
5. What is an example of a successful day for you at school?
6. How would you feel about being taken out of your regular class to get extra help at school?
7. How do you ask for help if you need it? How do you get your teacher’s attention?
8. hat causes you to get angry? What causes you to get frustrated? What causes you to give up?
9. Who are you most likely to go to at school if you feel you need help?
10. How hard is it for you to pay attention in classes?
11. What kind of directions—for example, written ones or spoken ones—are easier for you to understand and follow?

Appendix C: Sample Parent Questionnaire/Interview

1. Does your child complete homework? Do you sit with your child while he/she completes his/her homework? Do you have to remind him/her to complete homework often?
2. Do you think your child needs extra help at school? What kind of help?
3. When your child has been subject to disciplinary actions, do you understand the reasons for the action?
4. Please describe your child’s sleeping/eating habits.
5. What are some things that you have observed at school that works with your child? What are some interventions that do not seem to have worked?
6. Is there an adult at school that you feel your child trusts? What do you think contributes to their relationship?
7. How does your child interact with siblings or other family members?
8. What are some of the household rules your child must follow? What kinds of chores does s/he have to do, and does s/he need prompting or reminders to complete them?
9. How many hours does your child watch television each day and what sort of supervision does s/he have during this time?
10. What sort of family activities—for example a common suppertime, reading stories together, or having a “family night”—does your child engage in?
11. How does your child spend his/her spare time?
12. How does your child respond to affection?
13. What are your long-term goals/expectations for your child?
14. Are there concerns about your child’s behavior or his/her progress in school?

Appendix D: Teacher Questionnaire Informational Letter

The teacher questionnaire will be completed on paper. The following letter will accompany the teacher questionnaire:

Dear Teacher,

We are conducting a short-term formal research project to find ways to best educate children with emotional difficulties, learning disabilities, and other forms of EBDs. We hope that you will take the time to complete the following questionnaire to help us in this process. As always, our intent is to improve the offerings at the after-school program, and finding out more about you and the students in your class will help us do so better.

The questionnaire below asks personal questions—questions you may find difficult to answer. Please be assured that all your responses will be treated confidentially. Upon the completion of the research, we will create both a teacher’s handbook and a parent’s handbook which will indicate ways to best manage the problems we may face. The purpose of the handbooks is to provide generalized information to the respective parties. Your privacy is of utmost importance to us; at no point will personal or other identifiable information be used in these handbooks.

Please return this questionnaire within one month of receipt. If you need to contact us for additional information before completing the questionnaire, please refer all correspondence to:

[CONTACT NAME]
[CONTACT PHONE NUMBER(S)]
[CONTACT EMAIL ADDRESS(ES)]

Thank you for your time and patience,

Sincerely,

[SIGNED]

I, [TEACHER NAME], understand the questionnaire and its purpose and agree to take part in the research process.

[SIGNED], [DATED]

Appendix E: Sample Teacher Questionnaire

1. What are the student’s best subjects? Why do you think the student is strongest in those subjects?
2. What are some specific behaviors exhibited by the student that cause you concern? What is your response when this happens? How do other students react?
3. Do you believe that the student is a problem instigator, or do you think that the student is usually reacting to other students?
4. Does the student come to class prepared?
5. Is the student easily distracted? What type and frequency of prompting is necessary to get the student back on task? What are some distractions for the student?
6. What is the nature and frequency of your interaction with the student’s parents?
7. What interventions have you tried with this student, and how have they worked?
8. What is the student’s reaction to criticism, correction, and discipline? How does the student react when s/he fails or gets frustrated? What is the student’s reaction when an activity demands their use of new skills?
9. How would you compare the student’s interactivity level in different group sizes ranging from individual work, to small groups (five students maximum), to medium-sized groups (5-15 students), to large groups (over 15 students)?
10. What does the student say about how s/he spends time outside of school?
11. How would you compare the student’s abilities to complete daily homework with the ability to complete long-term assignments?
12. Does the student appear to seek excessive attention from either you or from classmates by engaging in tactics including excessive swearing, being disruptive, embellishing stories, or playing the “class clown”?
13. Does the student currently receive any special education services?

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1. Some questions adapted and modified from Boreson, L. (n.d.). Using Interviews to Collect Behavioral Data. Retrieved, August 8, 2006 from http://dpi.wi.gov/sped/ed.html [back]

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