Attachment R
OMB Control # 0584-0524
Expiration Date: 03/31/2013
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.
Parent Consent Form
About the Project
Your son or daughter is going to take part in a group discussion with 5-6 other children, as part of a research project on behalf of a federal government nutrition program. The group discussion will be about health and nutrition. By taking part in this project, your child will be helping to show what children (grades 6-8) think about nutrition and health.
A female researcher will lead the discussion, which will last about 60 minutes. The researcher will ask the group about what they do to be healthy, what are their favorite things to do, and what part of being healthy is challenging. They will also see messages designed to help children in their age range understand more about nutrition and health. Your son or daughter does not have to participate in this group if he or she does not want to. If he or she chooses to participate, he or she does not have to answer any questions he or she does not want to answer, and he or she may leave the group at any time without penalty or loss of benefits.
Some of the people working on this project will observe the groups. We will also audiotape the group to make sure our report is complete and accurate. These tapes will only be used for research. Everything your son or daughter says will be kept as private as allowed by law. His or her name will not be used in the report.
I agree to let my son or daughter take part in this group discussion. I have read the Parent Permission Form and understand that the group will discuss my child’s opinions about health and nutrition.
Parent’s Signature: ____________________________________________________
Parent’s Name (Please print): ____________________________________________
Date:
___________
Child’s Name:
_____________________________________________________
| File Type | application/vnd.openxmlformats-officedocument.wordprocessingml.document |
| File Title | Consent Form |
| Author | MIS |
| File Modified | 0000-00-00 |
| File Created | 2021-02-02 |