consent form as used for survey

Informed Consent Form

Survey on ESL Instructor use of available technology at Pacoima Skills Center


The purpose of this study is to examine the amount of awareness that ESL instructors at Pacoima Skills Center have of the types of technology available to them for use in their classrooms at Pacoima Skills Center and to determine how instructors use that technology. This study is completely voluntarily and is not a requirement or duty of your employment.

The information generated from this study will be used primarily to fulfill the project requirements of a class in educational research that Barry Bakin is taking as part of a Masters of Education in Instructional Technology at American Intercontinental University (AIULA). Results may be shared with the administration and staff of Pacoima Skills Center at the completion of the class.

Your participation is voluntary and confidential. Your names will not be on your survey response forms. You are free to withdraw from the research study (not turn it in) at any time or to decline to answer any questions without penalty. The study involves no risk to your physical or mental health beyond those encountered in the normal course of everyday life.



I consent to take part in the survey on ESL Instructor use of available technology at Pacoima Skills Center with the understanding that my responses will remain anonymous and no personal information will be collected nor divulged. I am aware that this survey is a project for a class in educational research and I permit Barry Bakin to utilize the responses I will be giving as part of his class assignment. I am aware that results of this research may be shared with the administration and staff of Pacoima Skills Center at the conclusion of his class.


I agree and consent (mark an X in the box) BOX APPEARS HERE ON DOCUMENT


I disagree and do not consent (mark an X in the box) BOX APPEARS HERE ON DOCUMENT