Attachment I: Confidentiality Agreement (Mothers of Children)

Attachment I

OMB BURDEN STATEMENT: According to the Paperwork Reduction Act of 1995, no persons are required to respond to a collection of information unless it displays a valid OMB control number. The valid OMB control number for this information collection is [0584-0524]. The time to complete this information collection is estimated to average 10 minutes per response, including the time for reviewing instructions, searching existing data sources, gathering and maintaining the data needed, and completing and reviewing the collection of information.

USDA Food and Nutrition Service

CONFIDENTIALITY AGREEMENT

I, __________________________(print name), and my child, _____________________________ (print name) agree to keep all information shown and discussed during the USDA focus group in which my child is participating in the strictest confidence.

I agree not to discuss, publish, or otherwise divulge any information I am exposed to, in whole or in part, in any manner or form through my child’s participation.

My child’s comments will be kept confidential and only used for research purposes. His or her name, as well as my name, will not be divulged in any reports of this focus group.

Signed:___________________________ Dated: ____________________