Chemistry Course Survey Consent Form for Students

The Learning through Evaluation, Adaptation and Dissemination (LEAD) Center is conducting a survey of some of the Chemistry Department's undergraduate courses. The survey is designed to assist faculty in understanding the effects of course innovations on students' learning experiences and may lead to improvements in the teaching of chemistry nationwide.

We are asking students who are enrolled in the participating lectures to complete a brief survey about their learning experiences in the course. The survey should take about ten minutes to complete. In order to correlate responses with demographic data and measures of achievement we are asking you to write your Student I.D. number on the survey.

All student responses will be held strictly confidential. The LEAD Center will generalize about student responses so as to obscure the identity of any particular students before reporting any survey findings. The LEAD Center may publish papers based on the results of this survey, but these materials will contain no information that would identify particular students.

Participation is completely voluntary. (Students choosing not to participate may simply return a blank survey). Refusal to participate will have no effect on your grade. There are no formal benefits or risks associated with participation.

Any questions you have you may ask now, or you may call Dr. Susan Millar, Director, LEAD Center, at 265-5943.

I have read the above and give my consent to participate in the study.

The LEAD Center wishes to thank you for participating in this national study of how students learn in college chemistry courses. The questions in the survey are intended to help LEAD Center researchers understand your experiences in the chemistry course in which this survey is being administered. Your thoughtful responses to the questions in this survey will enable us to help faculty across the nation improve chemistry education.

Copies of this consent form can be obtained at the LEAD Center room 427, 1402 University Ave.

Please fill in your responses on the separate bubble sheet or write in the space provided as indicated.

BACKGROUND:

1)	Institution		course number (write in here): __________
	For...		UW-Madison			Madison Area Technical College			San Jose State University
	Fill in...		0			1			2
2)	Sex
	For...		female			male
	Fill in...		0			1
3)	Citizenship
	For...		U.S.			Other
	Fill in...		0			1
4)	U.S. ethnic code
	For...	Fill in...
	white (not Hispanic) or other	0
	Cambodian, Laotian, Vietnamese after 1975	1
	other Asian or Pacific Islander	2
	American Indian or Alaskan Native	3
	Hispanic/Latino	4
	Black/Afro-American	5	0	1	2	3	4	5
5)	College rank:
	For...	Fill in...
	no college rank	0
	freshman	1
	sophomore	2
	junior	3
	senior	4	0	1	2	3	4
6)	semesters of high school chemistry:		0	1	2	3	4	over 3 (fill in bubble 4)
7)	semesters of college level chemistry completed:		0	1	2	3	4	5	6	7	8

For each group of factors below please fill in a number on the bubble sheet to indicate the relative impact of each factor on your LEARNING overall in this course.

		relative impact on your LEARNING overall
	PEOPLE	not applicable	negative			neutral	positive
8)	professor	0	1	2	3	4	5	6	7
9)	TA/lab instructor	0	1	2	3	4	5	6	7
10)	friends/informal groups	0	1	2	3	4	5	6	7
11)	course organized groups	0	1	2	3	4	5	6	7
12)	other people specify here: ____________________	0	1	2	3	4	5	6	7
		relative impact on your LEARNING overall
	ACTIVITIES
13)	lecture	0	1	2	3	4	5	6	7
14)	lab	0	1	2	3	4	5	6	7
15)	discussion/problem sessions	0	1	2	3	4	5	6	7
16)	exams	0	1	2	3	4	5	6	7
17)	quizzes	0	1	2	3	4	5	6	7
18)	homework/exercises	0	1	2	3	4	5	6	7
19)	other people specify here: ____________________	0	1	2	3	4	5	6	7
		relative impact on your LEARNING overall
	MATERIALS
20)	textbook(s)	0	1	2	3	4	5	6	7
21)	lab book(s)	0	1	2	3	4	5	6	7
22)	computer materials	0	1	2	3	4	5	6	7
23)	other materials specify here: ____________________	0	1	2	3	4	5	6	7

For each group of factors below please fill in a number on the bubble sheet to indicate the relative impact of each factor on your CONFIDENCE in your ability to understand and do chemistry.

		relative impact on your CONFIDENCE
	PEOPLE	not applicable	negative			neutral	positive
24)	professor	0	1	2	3	4	5	6	7
25)	TA/lab instructor	0	1	2	3	4	5	6	7
26)	friends/informal groups	0	1	2	3	4	5	6	7
27)	course organized groups	0	1	2	3	4	5	6	7
28)	other people specify here: ____________________	0	1	2	3	4	5	6	7
		relative impact on your CONFIDENCE
	ACTIVITIES
29)	lecture	0	1	2	3	4	5	6	7
30)	lab	0	1	2	3	4	5	6	7
31)	discussion/problem sessions	0	1	2	3	4	5	6	7
32)	exams	0	1	2	3	4	5	6	7
33)	quizzes	0	1	2	3	4	5	6	7
34)	homework/exercises	0	1	2	3	4	5	6	7
35)	other people specify here: ____________________	0	1	2	3	4	5	6	7
		relative impact on your CONFIDENCE
	MATERIALS
36)	textbook(s)	0	1	2	3	4	5	6	7
37)	lab book(s)	0	1	2	3	4	5	6	7
38)	computer materials	0	1	2	3	4	5	6	7
39)	other materials specify here: ____________________	0	1	2	3	4	5	6	7

For each group of factors below please fill in a number on the bubble sheet to indicate the relative impact of each factor on your ENTHUSIASM for learning chemistry.

		relative impact on your CONFIDENCE
	PEOPLE	not applicable	negative			neutral	positive
40)	professor	0	1	2	3	4	5	6	7
41)	TA/lab instructor	0	1	2	3	4	5	6	7
42)	friends/informal groups	0	1	2	3	4	5	6	7
43)	course organized groups	0	1	2	3	4	5	6	7
44)	other people specify here: ____________________	0	1	2	3	4	5	6	7
		relative impact on your ENTHUSIASM for learning chemistry.
	ACTIVITIES
45)	lecture	0	1	2	3	4	5	6	7
46)	lab	0	1	2	3	4	5	6	7
47)	discussion/problem sessions	0	1	2	3	4	5	6	7
48)	exams	0	1	2	3	4	5	6	7
49)	quizzes	0	1	2	3	4	5	6	7
50)	homework/exercises	0	1	2	3	4	5	6	7
51)	other people specify here: ____________________	0	1	2	3	4	5	6	7
		relative impact on your ENTHUSIASM for learning chemistry.
	MATERIALS
52)	textbook(s)	0	1	2	3	4	5	6	7
53)	lab book(s)	0	1	2	3	4	5	6	7
54)	computer materials	0	1	2	3	4	5	6	7
55)	other materials specify here: ____________________	0	1	2	3	4	5	6	7

Please compare your CONFIDENCE levels in the areas below BEFORE and AFTER taking this course. (Fill in a number on the bubble sheet for each row.)

			confidence level
CONFIDENCE IN YOUR ABILITY TO...			low			high
understand key concepts of chemistry...............	56)	before	0	1	2	3	4	5
	57)	after	0	1	2	3	4	5
solve chemistry problems...............	58)	before	0	1	2	3	4	5
	59)	after	0	1	2	3	4	5
understand the chemistry underlying lab experiments...............	60)	before	0	1	2	3	4	5
	61)	after	0	1	2	3	4	5
perform lab experiments...............	62)	before	0	1	2	3	4	5
	63)	after	0	1	2	3	4	5
visualize key concepts of chemistry...............	64)	before	0	1	2	3	4	5
	65)	after	0	1	2	3	4	5
apply your knowledge of chemistry to the real world...............	66)	before	0	1	2	3	4	5
	67)	after	0	1	2	3	4	5
understand other areas of science...............	68)	before	0	1	2	3	4	5
	69)	after	0	1	2	3	4	5
succeed in another chemistry course...............	70)	before	0	1	2	3	4	5
	71)	after	0	1	2	3	4	5
succeed in a chemistry-related discipline...............	72)	before	0	1	2	3	4	5
	73)	after	0	1	2	3	4	5

Please compare your INTEREST levels in the areas below BEFORE and AFTER taking this course. (Fill in a number on the bubble sheet for each row.)

			interest level
INTEREST IN...			low			high
studying chemistry in general...............	74)	before	0	1	2	3	4	5
	75)	after	0	1	2	3	4	5
taking more chemistry...............	76)	before	0	1	2	3	4	5
	77)	after	0	1	2	3	4	5
pursuing a chemistry-relatele major...............	78)	before	0	1	2	3	4	5
	79)	after	0	1	2	3	4	5
pursuing a science-related field...............	80)	before	0	1	2	3	4	5
	81)	after	0	1	2	3	4	5
working with others to learn science...............	82)	before	0	1	2	3	4	5
	83)	after	0	1	2	3	4	5
chemistry in industry...............	84)	before	0	1	2	3	4	5
	85)	after	0	1	2	3	4	5