Appendix

A
Parental Consent Form

Nebraska Wesleyan University

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

Sensory Interventions to Create a Calm Classroom Learning Environment

Your child is being invited to participate in a research study conducted by Dylan Doggett.
Your child’s teacher is a graduate student at Nebraska Wesleyan University. Since she/he is
under the age of 19, their parent/guardian must give the researcher permission to invite
them to be in this study. Your child is being asked to participate in the study because he/she
fits in the criteria of this study, that he/she is a student in a self-contained classroom,
diagnosed with Autism and in grades 3rd through 5th. 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 identify if a sensory intervention lessens the
number of outbursts throughout the school day and if it shortens the length of outbursts. I
hope that a result of the study is to create a more calm classroom atmosphere by having less
outbursts and shorter outbursts from students. I want to know this in order to help teachers
and to justify the use of sensory activities along with creating more positive calm behaviors.

What Will Occur In This Study:

Sensory activities are becoming more and more popular in the world of special education
and I would like to start incorporating them more into our learning day. 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. What this will look like is:

Students will be receive a lesson on how to use sensory activities and taught about the
transition signals. Students will then receive a 15 minute sensory break from 9:00-9:15 a.m..
Students will pick which sensory activity they would like to play with and then data will be
recorded on your child’s behaviors throughout the day. Data will be taken using tally marks
on a form recording the number of outbursts and the length of the outburst. Students will
receive another sensory break again in the afternoon from 1:00-1:15 p.m.. Data will be
again recorded using the exact same style. This will last for a total of six weeks. Following
the intervention I will be analyzing the data.

If you agree to let you child participate, data from the following will be included in the
study:

• Number of outbursts and length of outburst

• Sensory activity choice: Therapy Sand, Therapy Putty, or Weighted Vest

If you do not agree to let you child participate their data will not be included in the study.
You as the parent/guardian can stop their participation at any time, by asking that their
data not be included in the research study. No student name will be reported in this study.

Potential Risks & Discomforts:

You child will face no more than the minimal risks associated with daily classroom
participation if they decide to participate in this study. You as a parent can stop their
participation at any time, by asking that their data not be used in this study. No student
names will be reported in this study.

Anticipated Benefits:

Participants may benefit from having less outbursts, shortened length of outbursts and
feeling more calm. This could positively affect their learning experience, their behaviors,
and other students learning experience.

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 forms and paper copies of data forms 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. Your decision on whether or not to
participate in this research study will have no influence on your or their present or future
status at Oak Valley Elementary, Omaha Public Schools, or Nebraska Wesleyan University.

Questions:

If you have questions about this study, please contact:

Researcher: Dylan Doggett (402-670-2103) Dylan.Doggett@ops.org

Advisor: Tanya Martin 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 in order for you to decide whether to allow your child to participate in this
study.


Name of Child Invited to be in the Study (Please Print): _________________________________

Please mark one of 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: ________________