Youth Assent Form 

Nebraska Wesleyan University 

Youth Assent Form to Participate in a Research Study 
Improving Engagement in a Fourth Grade Classroom by Implementing 3 Good Things 
 
You are being invited to participate in a research study conducted by Hailey McGargill, who is
your teacher and 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 they fit the criteria of the study, that is, a fourth grade student. You
should read the information below and ask questions about anything you do not understand
before deciding whether or not to allow your child/ward to participate. 
 
Purpose of Study: 
 
The purpose of this research study is to identify changes among students when gratitude is
incorporated into their typical day. I hope that one result of this study is a positive change in
increasing engagement in school. I want to know this in order to help schools and teachers to
keep students engaged throughout the school day. 
 
What Will Occur In This Study: 
 
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. The two things that we
will be doing the classroom this quarter are: 
 
1. All students will be asked to complete a short survey regarding their attitude toward
school. The survey will be given to your child at the beginning of the quarter and again at
the end of the quarter and will take 10-15 minutes to complete. This will not impact your
child’s grade in any way.
 
1. All students will be asked to write down 3 good things that happened to him/her within
the past 24 hours and also write down why those good things happened and how the events
made the student feel. This will take place during the student’s morning work time and will not
impact your child’s grade in any way.
 
1. All students will be asked to rate how they are feeling about school at the beginning of
the day and at the end of the day to see how realizing what they are grateful for can impact their
mindset about school. This will not impact your child’s grade in any way.
 
I am asking if you will let me use the results of the survey and lunch discussions as part of my
study. If you agree to be in the study, I will use your responses from the following:  
 
● Pre- and post-assessment survey response
● Teacher observation
● How you rate your day at both the beginning and end of the day
 
If you do not agree to participate, your data (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 pre- and
post-assessments or during the daily journal writing, you may choose to not answer some or all
of the questions, or to not share your journal writing. You can stop participation at anytime, 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 your 3 good things and why they
happened. You may also benefit from knowing they are contributing to the research and
teaching practice which could positively affect your own learning experience, that of your peers,
and potentially the practice of other teachers 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 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 your present future status at St. Gerald Catholic
School, the Archdiocese of Omaha, or Nebraska Wesleyan University.  
 
Questions: 
 
If you have questions about this study, please contact: 
 
Researcher: Hailey McGargill (402) 917-0402 ​hmcgargill@stgerald.org 
 
Advisors: Dr. Randal Ernst (402) 465-2310 ​rernst@nebrwesleyan.edu

Dr. Tanya Martin (402) 253-6522 ​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 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