Healthy School Environment

Attachment Q

OMB Control # 0584-0524

Expiration Date: 04/30/2013

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 as part of the 15 minutes for the screener, including the time for reviewing instructions and completing the information.

USDA Food and Nutrition Service

Agreement on Security of Comments for Parents

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.

Signed:___________________________ Dated: ____________________

Your child’s comments will be kept private and only used for research purposes except as otherwise required by law. His or her name, as well as my name, will not be divulged in any reports of this focus group.