LSAMP Consent

LSAMP Program Evaluation:

Director and Staff Interview Consent Form

Thank you for volunteering to participate in an evaluation of the Louis Stokes Alliance for Minority Participation Program (LSAMP) conducted by NORC at the University of Chicago (NORC) on behalf of the National Science Foundation (NSF). For this evaluation, we will be conducting interviews with staff at select participating institutions.

Time involvement: This interview will take approximately one hour, and we are required to let you know that this was cleared by the Office of Management and Budget under clearance number 3145-XXXX. If you have any comments on this burden time, we will provide you with the contact information for the NSF clearance officer.

How data will be used: All data collected through this study will be used for research purposes only. Researchers from NORC will use the data to better understand how participating in LSAMP has shaped STEM-related practices at participating institutions.

Risks and benefits: This research presents the same amount of risk that you experience during a typical workday. The benefits include providing valuable information to the NSF about LSAMP programming and what supports or hinders its role in the recruitment, support, and retention of STEM undergraduate and graduate students.

Confidentiality: Data collected through this study will be completely confidential and will be used only for the purpose of research. In addition to de-identifying quotations provided in interviews, we will not share your individual responses with other staff or anyone else outside the project except as required by law. We will not identify any individuals by name in our study reports. Your responses will be combined with others and reported in the aggregate. If quotations are used in any written reports, they will be included only for illustrative purposes and will not be attributed to any individual. All data will be destroyed within five years of the conclusion of the research study.

Participants’ Rights:

• My participation in research is voluntary. I may refuse to participate or can withdraw at any time without penalty.

• If, during the course of the study, the research team learns of new information that may influence my choice participation, the research team will provide this information to me.

• Any information from the research project that personally identifies me will not be voluntarily released or disclosed without my separate consent, except as specifically required by law.

• If at any time I have any questions regarding the research or my participation, I can contact the principal investigators:

  • Debbie Kim, kim-debbie@norc.org

  • Neil Seftor, seftor-neil@norc.org

• If at any time I have comments, or concerns regarding the conduct of the research or questions about my rights as a research participant, I should contact NORC’s Institutional Review Board (IRB). The phone number for the IRB is 866-309-0542.

SIGNATURE

I have read and understand all of the above statements and provide my consent for interview.

Print First and Last Name (No Abbreviations or Nicknames)
Signature	Date
Email Address	Cell Phone Number
	Institution Name

  

Page 2 of 2