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Jefferson County Public Schools
*** For your convenience this Research Request Form may by downloaded in WORD or PDF format. ***
Name _______________________________________________________ Phone _______________
Home Address _____________________________________________________________________
Street City State Zip
E-Mail Address _________________________________________________Fax ________________
Educational or Business Affiliation
Street City State Zip
Is this study part of your work for a degree? _________________ Yes ___________________ No
If yes, check the following:
________ Ph.D .________ Ed.D ________M.A./M.S. ________ Undergraduate_________ Other
University or College______________________________________________________________
Advisors Name and Title___________________________________________________________
Academic Department _________________________________ Phone No.__________________
PLEASE ANSWER THE FOLLOWING QUESTIONS ON A SEPARATE SHEET
1.Title and purpose of study?
2.What do you plan to do? Give specific information on experimental design, sampling, measuring instruments and data collection procedures. What instructions will be given to students or staff? If you have a graduate school or grant proposal, attach a copy. If unstandardized instruments are to be used, attach copies.
3.What request are you making of the Jefferson County Public Schools? Specify number of students and staff to be involved, length of time, and schedule, if pertinent.If specific schools are to be involved, designate them, or describe the characteristics of the schools you wish to sample.
4.If you have discussed this proposal with Jefferson County School personnel, indicate with whom you have talked and the nature of your discussion.
5.What practical implications does your study have to the Jefferson County school system? (If none, say none, but describe what value the study may have for children in general.)
6.Have you conducted previous studies in the Jefferson County Public Schools? yes no If yes, give sufficient information about the most recent study or most pertinent study so that it can be located, i.e., date, who your contact was, title or nature of study.
7. Is there previous research which would be helpful in understanding your proposal? (Reprints or summaries of such studies will help speed the processing of your proposal.)
8.What procedures will you use to report the findings of your study to participating schools?
9 Have you received permission for this study from your institutions Human Subjects committee?
10.List all funding sources for your study.
11.List the name of all personnel who will be involved in carrying out field operations.
12. Do you have any objections to publicity on your study at this time? yes no
13. When do you wish to begin collecting your data?
I have read the statement of Conditions Related to Conducting Research in the Jefferson County Public Schools System and agree to abide by them if my research request is approved.
Signature of Advisor or teacher (if appropriate) Date
Dr. Marco Munoz
Jefferson County Public Schools
Accountability, Research and Planning
VanHoose Education Center
3332 Newburg Road
Louisville, KY 40218
Conditions Related to Conducting Research in the Jefferson County Public Schools:
1.All persons wishing to conduct research in the Jefferson County Public Schools must make a written request. A form for this purpose is provided.
2. All research requests are reviewed by the Research Specialist and appropriate district staff.
3. Approval does not guarantee participation of a particular school in the research study. If the project interferes with the educational process in a school, the principal may request that his or her school be excluded from the study. Researchers are cautioned that they must ask for the cooperation of principals and teachers and not assume that permission to conduct a study automatically guarantees the inclusion of any particular school.
4. Research activities conducted by district employees which are not part of their job responsibility and authority also require approval by the Research Specialist.
5. Written parental permission is required prior to each child participating in a study. Researchers requesting parent permission must provide each parent a written explanation describing the study in order to assure that permission reflects informed consent.
6. All persons conducting research in the Jefferson County Public Schools must guarantee anonymity of the individual children, schools, and school personnel in reporting the results, unless written approval is obtained from the parents of the children, the school principal, the school staff involved, and the Research Specialist.
7. All researchers must comply with the provisions of the Protection for the Rights and Privacy of Parents and Students Act, the Protection of Human Subjects Rules and Regulations*, and the Procedures for confidentiality of Student Education Records of the Jefferson County Public Schools.
8. One copy of the final report and a summary or abstract of the study must be sent to the Research Unit, Jefferson County Public Schools, when the study has been completed.
9. A one-page progress report is to be submitted every six months. Progress report forms will be mailed to the researchers.
10. All publications emanating from studies in schools should acknowledge the contribution of the Jefferson County Public Schools unless requests to the contrary are made or unless the identification of the District would jeopardize future research efforts or school programs.
11. Research activities, including tests and questionnaires, other than those described in the approved research proposal, are not to be used without express written permission from the Research Specialist, nor are schools other than those described in the approval letter to be involved.
12. Since all research conducted in the schools ultimately depends on the good will and cooperation of teachers and principals, it is imperative that all researchers keep participants informed of the progress of the study and its final results. Any information the investigator can give the schools that will be of practical value in helping children will help promote research in the schools.
13. Draft copies of investigations will be reviewed by the Research Specialist for correctness of facts referring to the Jefferson County Public Schools. This review does not relate to statements of opinion nor to value judgments.
14. In some situations where the research student has obvious practical value for the schools, assistance (other than financial) may be provided by the Jefferson County Public Schools. Consultation on research design and methodology is always available. Questions may be directed to the Research Specialist, Research Unit, (502) 485-3036.
15. Violation of standards stipulated in Conditions Related to Conducting Research in the Jefferson County Public Schools will result in revoking of permission to conduct research in the district.
*See: Public Law 93-380, Section 513 and following for Protection of the Rights and Privacy of Parents and Student Act
Federal Register, May 30, 1974, Vol. 39, No. 105, p. 18, 914 ff, for Protection of Human Subjects Rules and Regulations.