Site: ______________________________ OMB Control # 0584-0524
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 10 minutes for the screener, including the time for reviewing instructions and completing the information.
September 13, 2011
Dear Parent,
My name is [Researcher’s Name] and I work for the Michael Cohen Group, a research firm that specializes in children, education and media.
We are currently working with your child’s school to develop effective ways to talk with children about nutrition. This effort is being sponsored by the United States Department of Agriculture. To this end, we are interviewing 5th and 6th grade children and their parents and teachers to help develop strategies and hands-on activities that are educational and relevant for children and parents and convenient for teachers.
Included with this letter you will find consent forms with additional information and brief survey. If you would like to participate in the interview please complete the consent form and the survey and return them to your child’s teacher. If your child wishes to participate as well, please complete the “parent consent for child participation form”.
Thank you for your consideration and we look forward to working with you.
[Researcher’s Name]
Parents/Caregivers Survey for Participation in Focus Groups
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 10 minutes for the screener, including the time for reviewing instructions and completing the information.
Please choose the option that best answers each question for you.
Are you the parent or guardian of any children in the 5th or 6th grade who live at home with you?
( ) yes
( ) no
Please indicate the ages and gender of all children who are in the 5th or 6th grade living at home with you.
Age 9 ( ) boy / ( ) girl
Age 10 ( ) boy / ( ) girl
Age 11 ( ) boy / ( ) girl
Age 12 ( ) boy / ( ) girl
Ethnicity
( ) Hispanic or Latino
( ) Not Hispanic or Latino
Race (select one or more)
( ) American Indian or Alaskan Native
( ) Asian
( ) Black or African American
( ) Native Hawaiian or Other Pacific Islander
( ) White
Into which of the following categories does your annual household income fall?
( ) Under $20,000
( ) $20-$39,000
( ) $40-49,999
( ) $50-79,999
( ) $80-99,999
( ) $100-$120,000
( ) Over $120,000
Which of the following represents the level of formal education you have completed to this point?
( ) Have completed some high school
( ) Have a high school diploma
( ) Have completed some college
( ) Have a college degree
( ) Have completed some graduate work
( ) Have a graduate degree or more
Informed Consent Form for Parent
STUDY TITLE: Project JMH Gardening: Formative Curriculum Research
PROTOCOL NUMBER: 229G
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PRINCIPAL INVESTIGATOR:
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Michael Cohen, Ph.D.
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TELEPHONE:
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212-431-2252
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ADDRESS: |
SoHo Research Centre 375 West Broadway, Suite 502 New York, NY 10012
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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 10 minutes for the screener, including the time for reviewing instructions and completing the information.
BACKGROUND AND PURPOSE:
You are invited to participate in a research study conducted by Michael Cohen Group as part of a United States Department of Agriculture sponsored effort to develop strategies and hands-on activities to help 5th and 6th graders learn more about nutrition. Michael Cohen Group is an international research and consulting firm that specializes in children and educational programs.
We are currently researching various aspects of nutrition and nutritional education for 5th & 6th grade children. If you participate, you will be asked questions about this topic. We are most interested in your opinions about and experience with nutrition and nutritional messages for children and families.
PROCEDURES:
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 15 minutes for reviewing instructions, searching existing data sources, gathering and maintaining the data needed, and completing and reviewing the collection of information.
As part of this research project, you will be asked to join a researcher in a room and participate in an interview about nutrition. The interview will be done in a group setting with other parent’s of 5th & 6th grade students like you. The interview will last about 90 minutes. About 30 parents will participate in total. At the end of the group interview, you will be given a brief survey with additional questions about nutrition.
POSSIBLE RISKS AND BENEFITS:
We do not anticipate any risks associated with being in this study. We do not promise that you will receive any benefits from this study. However, we do anticipate that most people will enjoy participating in the research process.
COMPENSATION:
At the end of the research activities, you will receive $50.
PARTICIPANTS’ RIGHTS:
Participation in this study is voluntary. We will not work with you unless you give your consent. You have the right to change your mind and withdraw your consent or discontinue participation at any time without any penalty or loss of the benefits to which you are otherwise entitled. You have the right to refuse to answer particular questions. Your comments will be kept secure and only used for research purposes, except as otherwise required by law. The research will not be used in any advertising. You will not be identified in any reports. All data will be identified only by an ID number, not by any name. The research may be audiotaped or videotaped for research purposes only. Any audio or videotapes collected as part of the research will be destroyed once the study analysis is complete.
CONTACT INFORMATION:
Questions, Concerns, or Complaints: If you have any questions, concerns or complaints about this research study, its procedures, risks and benefits, please contact the Principal Investigator, at the telephone number listed on the first page of this form.
If you have any questions or complaints about your rights as a research subject, contact:
Mail:
Study Subject Adviser
Chesapeake Research Review, Inc.
7063 Columbia Gateway Drive, Suite 110
Columbia, MD 21046
Call collect: 410-884-2900
Email: [email protected]
Please complete the section below if you agree to participate.
I, _____________________________________, agree to participate in this research
[your name]
project with the Michael Cohen Group. I understand that I may stop participation at any time.
_______________________________________________ _________________
Signature Date
A copy of this consent form will be given to you to keep.
Parent or Legally Authorized Representative
Informed Consent Form for Student
STUDY TITLE: Project JMH Gardening: Formative Research
PROTOCOL NUMBER: 229G
|
|
PRINCIPAL INVESTIGATOR:
|
Michael Cohen, Ph.D.
|
TELEPHONE:
|
212-431-2252
|
ADDRESS: |
SoHo Research Centre 375 West Broadway, Suite 502 New York, NY 10012
|
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 10 minutes for the screener, including the time for reviewing instructions and completing the information.
BACKGROUND AND PURPOSE:
We are currently researching various aspects of nutrition and nutritional education for 5th and 6th grade children. If your child participates, s/he will be asked questions about this topic. We are most interested in your opinions about and experience with nutrition and nutritional messages for children and families.
PROCEDURES:
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 8 minutes for reviewing instructions and completing the collection of information.
As part of this research project, our team of researchers (all trained to work with children) will be visiting your child’s school. During our visit, researchers will introduce themselves to your child and explain that we will be doing some activities with them. The activities will be conducted at your child’s school and will last no longer than 60 minutes. This interview will be done in a group setting with other children at the center. About 60 children will participate in total across three different centers.
First, your child will be asked some introductory questions about health and nutrition. Then s/he will discuss activities and messages that may become part of a nutritional curriculum. We will ask your child for his/her opinions about the different activities. Finally, we will ask him/her to complete a brief survey about their food preferences.
POSSIBLE RISKS AND BENEFITS:
We do not anticipate any risks associated with being in this study. While we do not promise that your child will receive any benefits from this study, we anticipate that most children will enjoy participating in the research process.
COMPENSATION:
At the end of the study, your child will receive a toy or token worth $2-$3. Your child’s school will also receive a gift for helping us with this project.
PARTICIPANTS’ RIGHTS:
Participation in this study is voluntary. We will not work with your child unless you give your consent. If you give permission for your child to be in the study, but your child does not want to participate, then your child will not be in the study. Your child will be reminded that participation is voluntary by our researchers before the start of the activities. You and your child both have the right to change your mind and withdraw your consent or discontinue participation at any time without any penalty or loss of the benefits to which s/he is otherwise entitled. Your child has the right to refuse to answer particular questions. Your comments will be kept secure and only used for research purposes, except as otherwise required by law.
The research will not be used in any advertising. Your child will not be identified in any reports. All data will be identified only by an ID number, not by any child’s name. The research may be audiotaped or videotaped for research purposes only. Any audio or videotapes collected as part of the research will be destroyed once the study analysis is complete.
CONTACT INFORMATION:
Questions, Concerns, or Complaints: If you have any questions, concerns or complaints about this research study, its procedures, risks and benefits, please contact the Principal Investigator, at the telephone number listed on the first page of this form.
If you have any questions or complaints about your rights as a research subject, contact:
Mail:
Study Subject Adviser
Chesapeake Research Review, Inc.
7063 Columbia Gateway Drive, Suite 110
Columbia, MD 21046
Call collect: 410-884-2900
Email: [email protected]
Please discuss this study with your child. Please complete the section below if you agree to allow your child to participate.
My child, _____________________________________, has my permission to
[Name of Child]
participate in this research project with the Michael Cohen Group. I have also discussed the study with my child and s/he has indicated that s/he would like to participate in the study. My child and I both understand that either of us may stop my child’s participation at any time.
Child’s Date of Birth: __________________ Child’s age: ___ years, ___ months.
[Month/Day/Year]
_______________________________________________ _________________
Signature(s) of Parent(s) or Legal Guardian Date
_______________________________________________
Print First and Last name of Parent or Legal Guardian
A copy of this consent form will be given to you to keep.
| File Type | application/msword |
| File Title | OMB BURDEN STATEMENT: According to the Paperwork Reduction Act of 1995, no persons are required to respond to a collection of i |
| Author | Gerard O'Shea |
| Last Modified By | RBrown |
| File Modified | 2012-01-04 |
| File Created | 2012-01-04 |