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MADISON METRO SCHOOL DISTRICT
EXTERNAL RESEARCH COMMITTEE REQUEST FOR ACCESS
DATE ____________________________
NAME OF APPLICANT: __________________________________ PHONE: _________
ADDRESS: _________________________________________ ZIP CODE: _________
TITLE OF PROJECT: ____________________________________________________
______________________________________________________________________
E-MAIL ADDRESS: ______________________________________________________
1. Number of pupils required: ____________
2. Estimated total time required of each pupil: ____________
3. Number of teachers required: ____________
4. Estimated total time required of each teacher: ____________
5. Number of parents required: ____________
6. Estimated total time required of each parent: ____________
7. Number of other MMSD staff required: ____________
8. Estimated total time required of MMSD staff: ____________
9. Will material from the cumulative records of pupils or teachers be
required? YES NO If yes, what material?
__________________________________________________________________
10. Will subjects be paid? YES NO
11. At what grade levels and school(s) is the project to be conducted? _____________
12. During what time period is the project expected to
run? ___________________________
13. Will a pilot study be necessary first? YES NO
14. When will a report of the results of the project be available?
____________________________________
15. How will the anonymity of subjects be protected? _________________
__________________________________________________________________
16. How will parent permission be obtained? __________________________
17. Additional school resources needed: ______________________________
__________________________________________________________________
18. NAME AND SIGNATURE OF PROFESSOR SPONSORING THE RESEARCH, IF
UNIVERSITY BASED:
Name: _____________________________________________________
Signature: ________________________________________________
University & Department: _________________________________________
Planning/Research & Evaluation Home Page
Last Updated: August 11, 2006
Author: Kurt Kiefer,
kkiefer@madison.k12.wi.us
HTML Editor: Chris Burch,
cburch@madison.k12.wi.us
HTML Publisher: Joshua Roy,
jroy@madison.k12.wi.us
webmaster@madison.k12.wi.us