PARENT’S CONSENT FORM

Dear Parent/Guardian,

We are asking that your child take part in a survey.

The survey will contain few questions about your child’s motivation in reading. We are asking everyone
within the grade 7 levels to complete a survey to better understand the needs of children in reading.

This research study is voluntary. The survey will take only few minutes to complete. Your child can skip
questions that he or she does not want to answer or stop the survey at any time. The survey is
anonymous; no one will be able to know your child’s answers. Please tell your child not to include his or
her name or any other information that could be used to identify him or her in the survey responses in
order to protect the child’s private information.

I, (Name of Parent)_________________________________, give permission for my child, (Name

of child)______________________________________ to participate in the research project The study
has been explained to me and my questions answered to my satisfaction. I understand that my child’s
right to withdraw from participating or refuse to participate will be respected and that his/her responses
and identity will be kept confidential. I give this consent voluntarily.

Parent/Guardian Signature:

_________________________________ _______________________

Signature Date
 STUDENT/CHILD SURVEY

This is a survey about reading. Please read each question carefully and select the answer that best fits
you. There are no right or wrong answers. If you find a word you don’t know or have any questions while
you are taking the survey, please seek help from your teacher, parents or guardian.

PART 1: READING MOTIVATION

For each of the following statements about reading, please circle the number that best describes you.

Always Often Sometimes Never

1. I like to read because I feel happy when I read interested things. 4 3 2 1

2. If I am reading about an interesting topic, I forgot about the 4 3 2 1

time.
3. If my parents tell me something interesting, I like to read more 4 3 2 1
about it.
4. I usually learn difficult things by reading. 4 3 2 1

5. I like to read about new things and adventure stories. 4 3 2 1

PART 2: PARENTAL SUPPORT

For each of the following statements, please circle the number that best describes you. Parents may
include siblings, grandparents and extended family, and babysitters and caregivers.

Always Often Sometimes Never

1. My parents ask me if they can read with me. 4 3 2 1

2. My parent discusses the meanings of interesting or 4 3 2 1

unknown words
3. My parent and I talk about the pictures we see in the book. 4 3 2 1

4. We ask each other questions about what we are reading. 4 3 2 1

5. I enjoy spending time reading for fun with my parents. 4 3 2 1