Appendix C

Youth Consent Form

Nebraska Wesleyan University

Youth Informed Consent for a Minor to Participate in a Research Study

Random Acts of Kindness:
Teaching 6 Grade Students Peer Kindness through the Intervention “Random Acts of
th

Kindness”
You are being invited to participate in a research study conducted by Heather Muller, a
teacher at Cedar Bluffs Public School, who is a graduate student at Nebraska Wesleyan
University. Your parent or guardian has given the researcher permission to invite you to be
in a study I am doing. You are being asked to participate because you fit the criteria of this
study, that is, a sixth-grade student at Cedar Bluffs Public School. I will read the information
below to you. Ask questions about anything you do not understand before deciding if to
participate.
Purpose of the Study:
The purpose of this research study is to promote peer kindness throughout the classroom
and school. I want to build a positive classroom community, promoting kindness in our 6 th

grade classroom. I want to know this in order to help schools and teachers do a good job of
helping students foster peer relationships and overall school community.
What Will Occur in This Study:
There are two things that we will be doing in class this year that I would like to include in
my study.
3. All students will be asked to complete a short survey regarding their views towards
kindness of themselves, their peers, their teachers, and the overall school environment.
The survey will be given to your child at the beginning of the quarter in their home room
and will take 10-15 minutes of class time to complete. This will not impact your child’s
grade in any way.
4. All students will be asked to reflect in a journal on the Random Acts of Kindness
they partake in throughout the week. I will take notes on the thoughts of the students but
I will not record any student names in my notes.
If you agree to participate, I will use your responses in my study from the following:

· Pre- and post-assessment survey responses

· Discussion notes from journal reflections
If you do not agree to participate, your responses will not be included in the study data set.

Potential Risks & Discomforts:

You will face no more than the minimal risks associated with daily classroom participation
if you decide to participate in this study. If you feel any discomfort during or after the
surveys or during discussions, you may choose how many or few items you wish to
respond to on the survey or you may choose not to respond in group discussion. You can
stop participation at any time, by asking that your data not be included in the research
study. No student names will be reported in this study.

Anticipated Benefits:

You may benefit from thinking about and discussing their thoughts and feelings about peer
kindness. You may also benefit from knowing you are contributing to research and
teaching practice which could positively affect your relationships with peers, your
classroom environment, and potentially the school environment of other students in the
building.

Confidentiality & Privacy:

To protect your 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/assent forms and paper copies of the survey 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 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 you or their present or future status at Cedar
Bluffs Public School or Nebraska Wesleyan University.

Questions:

If you have questions about this study, please contact:

Researcher: Heather Muller (402) 380-5074 hmuller@nebrwesleyan.edu

Advisor: Dr. Randal Ernst (402) rernst2@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 under the age of 19, that you are aware
that your parent/guardian has given permission for you 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 to participate in this study.

Printed Name: ______________________________________________________________________

Signature: _____________________________________ Date:_________________

Research Participant