Appendix B

Parental Consent Form

Nebraska Wesleyan University

Parental/Guardian Informed Consent for a Minor to Participate in a Research Study

Random Acts of Kindness:
Teaching 6 Grade Students Peer Kindness through the Intervention “Random Acts of
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Kindness”
Your child is being invited to participate in a research study conducted by Heather Muller,
your child’s teacher who is a graduate student at Nebraska Wesleyan University. Since
he/she is under the age of 19, their parent or guardian must give the researcher permission
to invite them to be in this study. They are being asked to participate because they fit the
criteria of this study, that he/she is a sixth-grade student at Cedar Bluffs Public School. You
should read the information below and ask questions about anything you do not
understand before deciding whether or not to allow your child to participate.
Purpose of the Study:
The purpose of this research study is to promote peer kindness throughout the classroom
and school. I hope that one result of this study is a positive change in classroom kindness
amongst 6 grade students. I want to know this in order to help schools and teachers do a
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good job of helping students foster peer relationships and overall school community.
What Will Occur in This Study:
There are two regular classroom practices that I would like to use as part of my research
study. Regardless of whether or not students join the study, they will still participate in the
regular classroom practices. I am asking for your permission to invite your son/daughter to
be in the study so I can look more closely at results of the classroom practices. The two
things that we will be doing in the classroom this quarter are:
1. All students will be asked to complete a short survey regarding their views towards
kindness of themselves, their peers, their teachers, and the overall school environment.
The survey will be given to your child at the beginning of the quarter in their home room
and will take 10-15 minutes of class time to complete. This will not impact your child’s
grade in any way.
2. All students will be asked to reflect in a journal on the Random Acts of Kindness
they partake in throughout the week. I will take notes on the thoughts of the students but
I will not record any student names in my notes.
If you agree to let your child participate, data (their responses) from the following will be
included in the study:

· Pre- and post-assessment survey responses

· Discussion notes from journal reflections
If you do not agree to let your child participate, their data (responses) will not be included
in the study data set.

Potential Risks & Discomforts:

There will be no cost to the participants or the parents/guardians of the participants. No

more than the minimal risk associated with attending daily classes is associated with this
study. If students feel uncomfortable about answering any of the survey questions or about
discussing topics after journaling, they can decide to not answer some or all the questions.
They are free to stop participation at any time and they are free to leave the study at any
time without risking the rights to which they are already entitled with the researcher (their
teacher), with Cedar Bluffs Public Schools, and with Nebraska Wesleyan University. I will
keep all survey information confidential. I will not put names in my notetaking during
discussions.

Anticipated Benefits:

Participants may benefit from thinking about and discussing their thoughts and feelings
about peer kindness. They may also benefit from they are contributing to research and
teaching practice which could positively affect their relationships with peers, their
classroom environment, and potentially the school environment of other students in the
building.

Confidentiality & Privacy:

To protect their confidentiality and privacy I will take the following steps:

· Participant’s privacy will be protected by not using names or other identifying

information in any published reports or presentations.
· Signed consent/assent forms and paper copies of the survey will be kept in a
locked location and any electronic data will be kept on a password-protected computer.
Only the researcher and the research advisor will have access to the data.
· All data and signed informed consent forms will be kept for three years after the
completion of the study and then destroyed.
Participation and Withdrawal:

You are free to decline to allow your child to participate in this research study, or you may
withdraw your permission at any point, without penalty. The same is true for your child.
Your decision or their decision on whether or not to participate in this research study will
have no influence on you or their present or future status at Cedar Bluffs Public School or
Nebraska Wesleyan University.

Questions:
If you have questions about this study, please contact:

Researcher: Heather Muller (402) 380-5074 hmuller@nebrwesleyan.edu

Advisor: Dr. Tanya Martin (402) 253-6522 tmartin@nebrwesleyan.edu

This research has been reviewed and approved by the Nebraska Wesleyan University
Institutional Review Board (IRB). To ask questions about your child’s rights as a research
participant, you may contact the NWU-IRB by contacting Nancy Wehrbein, IRB
Coordinator, at (402) 465-2488, or at nwehrbei@nebrwesleyan.edu

Agreement:

By signing this form, you are indicating that you are the parent/guardian of an individual
who is under the age of 19 and who, with your permission, will be asked to participate in
this research project; that you are giving your permission for your child to participate in
this research; and that the purpose and nature of this research have been sufficiently
explained to you for you to decide whether to allow your child/guardian to participate in
this study.

Name of Child invited to be in Study (Please Print):

_______________________________________________

Please mark on the statements below; then sign and date.

I give consent for my student to be in the study.

I do not give consent for my student to be in the study.

Name and Signature of Parent/Legal Guardian:

Printed Name: ______________________________________________________________________

Signature: _________________________________________ Date: _________________

Parent/Guardian of Potential Research Participant