Parent/Guardian Rite of Refusal Form

PARENT/GUARDIAN RIGHT OF REFUSAL FORM

February 1, 2015 Dear Parents and/or Guardians:

My name is Jane Doe and I have been a student teacher and permanent substitute filling in for Ms. Goodteacher at Anywhere South High School this school year. I have also been pursuing my Master’s degree in Education at Benedictine University. I am currently in the process of completing my thesis and am ready to begin my required research study.

In a couple of weeks, I will be working with your child at Anywhere South and Ms. Goodteacher’s classes to study the motivations students have influencing their decisions on taking science classes beyond their two year requirement.

A child participating in this study will fill out one short survey consisting of 40 questions. They should each take less than fifteen minutes of class time to complete. This survey will be given on March 11th 2010.

I need your permission to have your child participate in this study. The information will in no way affect your child’s records. All collected data will be kept locked in a secure location at Benedictine University. The information obtained from the surveys is confidential and is not part of any formal schooling in any way. If you do not want your child to take part in this study, please fill out the form below and return to your student’s science teacher (Ms. Goodteacher) by March 6th 2015. If your child can participate, no response is required.

If you have any questions or concerns, please feel free to contact me at 630-123-4567 or [email protected] or the Chair of the Internal Review Board of Benedictine University, Dr. Alandra Devall at 630-829-6295. Thank you for your assistance.

Sincerely,

Jane Doe Master’s Degree Candidate

My child, ______, DOES NOT have my permission to participate in (Please print child’s first and last name) helping Jane Doe meet the requirements of a Masters Degree from Benedictine University. He/she may not fill out the survey given on March 11th 2015.

______Parent/Guardian Signature Date