Teacher Performance Assessment (edTPA™) and MAT Action Research – Release form for student participation

Dear Parent/Guardian (or Student at least 18 years of age):

I, ...[Daniel Perron] teacher preparation program at Lake Forest College and am currently student teaching in your
child’s classroom. Illinois participates in edTPA™, which means that, in order to complete my student teaching
assignment, I have to complete an assessment called the Teacher Performance Assessment. This assessment includes
submitting a video of me teaching a series of lessons in the classroom and examples of student work completed. In
the course of recording my teaching, your child may appear on the video. I will gather samples of student work to
submit as evidence of my teaching practice, which may include some of your child’s work. This is not an assessment
of your child’s performance. This is an assessment of my instruction, required by the Illinois State Board of Education
for me to obtain a Professional Educator License.
No student’s name will appear on any materials that are submitted, and materials will be kept confidential at all times
in a password-protected site that is accessible only to me. The video recordings and student work I submit will not be
made public in any way. Materials I submit will be reviewed by my edTPA supervisors who are professors at Lake
Forest College, and they will also be used by test developers under secure conditions for edTPA program development
and implementation, including scorer training, and to support continued program improvement activities such as
future validity and reliability studies. Participation by your child is voluntary and has no impact on the instruction or
grade they receive.
[for MAT students only] I am also enrolled in the Master of Arts in Teaching (MAT) licensure program. As part of this
MAT program, I am required by the Department of Education at Lake Forest College to complete an action research
project on a topic related to my teaching practice to improve my effectiveness as a teacher. To complete this study, I
will collect anonymous information about characteristics of your child’s classroom and/or their experiences, which
may include some of your child’s work. Findings from this study may be published in the Lake Forest College’s Teacher
Action Research Journal. Any and all information that can identify your child, their classroom, their school, or their
school district will be removed before publishing the findings. All information gathered for this project will be kept
confidential in a password-protected personal computer. Participation is voluntary. Accepting or refusing to
participate in this study will not affect your child’s instruction or grades in the classroom. There is no direct benefit
provided to students who participate. There are no risks of participating beyond common day to day risks.
This form is a request for your voluntary consent to include your child in the video and to collect the information I
need to complete both the edTPA and MAT action research. Please complete the second page of this document and
retain this page for your reference. If you have any questions about the use of this video or your child’s class work,
please contact the edTPA Coordinator at Lake Forest College, Dr. Jacquelynn Popp at 847-735-5081 or
popp@lakeforest.edu. If you have any questions about the use of the information for the MAT action research,
please contact the MAT Coordinator at Lake Forest College, Dr. Desmond Odugu at 847-735-5177 or
odugu@lakeforet.edu. Questions or concerns about the MAT research and consent process should be directed to
Dr. Kathryn Dohrmann (dohrnmann@lakeforest.edu), chair of the Lake Forest College Human Subjects Review
Committee.

Thank you for your consideration.

Lake Forest College Student Teacher Sigature:
[Daniel Perron Email: danielperron98@gmail.com]

RELEASE FORM FOR STUDENT PARTICIPATION

Student name: __________________________ Student’s school: ______________________________

I am the parent or legal guardian of the child named above. I have read and understand the project description
given in the letter provided at the top of this form, and voluntarily agree to the following (please check the
appropriate line below):

___ I DO give permission for my child to appear on video recordings and my child’s class work to be used in the
Teacher Performance Assessment of my child’s Student Teacher. I understand that my child’s name and any other
personally identifiable information about my child will not appear on any of the submitted materials.
___ I DO give permission for my child to participate in data collection for the MAT action research. I understand
that my child’s name and any other personally identifiable information about my child will not appear on any of the
submitted materials.

___ I DO NOT give permission for my child to appear on video recordings and my child’s class work to be used in the
Teacher Performance Assessment of my child’s Student Teacher.
___ I DO NOT give permission for my child to participate in any data collection for the MAT action research, and
understand that my child will be seated outside of the recorded activities.

Signature of Parent or Guardian: ___________________________ Date: ________________

Initial here to acknowledge E-signature: _______

I am the student named above and am at least 18 years of age. I have read and understand the project description
given at the letter provided at the top of this form, and agree to the following (please check the appropriate line
below):
___ I am at least 18 years of age and DO give permission for me to appear on video recordings and for my class work
to be used in the Teacher Performance Assessment of my Student Teacher. I understand that my name and any
other personally identifiable information about me will not appear on any of the submitted materials.
___ I am at least 18 years of age and DO give permission for me to participate in data collection for the MAT action
research. I understand that my name and any other personally identifiable information about me will not appear on
any of the submitted materials.

___ I am at least 18 years of age and DO NOT give permission for me to appear on video recordings and for my class
work to be used in the Teacher Performance Assessment of my Student Teacher.
___ I am at least 18 years of age and DO NOT give permission for me to participate in any data collection for the
MAT action research, and understand that I will be seated outside of the recorded activities.

Signature of Student: ___________________________ Date: ______________ Date of birth: __/__/____

Initial here to acknowledge E-signature: _______