MyPlate

Site: ______________________________ OMB Control # 0584-0524

Date: _____________________________ Expiration Date: 04/30/2013

Attachment A – Teacher Letter, Survey for Participation in Focus Groups and Informed Consent Form

Prepared by

Prepared for

JMH Education

January 2012

Research undertaken to inform the development of nutrition education materials for the U.S. Department of Agriculture Food and Nutrition Service

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.

[DATE], 2012

Dear Teacher,

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 school to develop effective ways to talk with children about nutrition. This effort is being sponsored by the United States Department of Agriculture (USDA). To this end, we are interested in getting feedback on three My Plate lesson plans for the following grade levels: Level 1 (grades 1-2); Level 2 (grades 3-4); and Level 3 (grades 5-6). An informational handout for parents/caregivers accompanies the lesson plans.

MyPlate is an icon created by the federal government to help prompt Americans to think about building a healthy plate at mealtimes. Released in June 2011, MyPlate emphasizes the fruit, vegetable, grains, protein and dairy food groups. The MyPlate lessons are being designed to replace existing USDA MyPyramid Classroom Materials. Input from teachers like you is critical to ensuring that these lessons are educational, relevant for children and parents and convenient for teachers.

Your participation will be to implement the lesson plan booklet (containing 3 lessons) in your class and support the recruiting of parents and children. Specifically, you would be responsible for:

1. Distributing packets (containing the letter of invitation, parent response form, and parent/caregiver consent form) to each of their students to take home to their parents

2. Collecting signed forms from students

3. Returning the completed forms to the principal after the agreed upon due date

4. Teaching the three (3) lessons during class time. (These lessons also include 4 activities which may be take-homes or out-of-class activities (for homework or extra).

5. Completing a brief educator journal about each lesson

6. Completing a 45-minute telephone interview about your experience with the lessons

7. Distributing and collecting student surveys before the first and after the last lesson

If you chose to participate, you will receive a cash stipend of $50 as a token of our appreciation.

Included with this letter you will find a consent form with additional information and a brief survey. If you would like to participate, please complete these forms and return them to your principal.

Thank you for your consideration and we look forward to working with you.

[Researcher’s Name]

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.

Teacher Survey for Participation in Focus Groups

Please choose the option that best answers each question for you.

1. What grade do you currently teach?

( ) 1^st Grade

( ) 2^nd Grade

( ) 3^rd Grade

( ) 4^th Grade

( ) 5^th Grade

( ) 6^th Grade

2. How many years have you been teaching?

( ) First year

( ) 2-5 years

( ) 5-10 years

( ) Over 10 years

3. 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

4. Do you currently teach nutrition in your classroom?

( ) Yes

( ) No

5. Would you be willing to implement the lesson plan booklet (containing 3 lessons) in your class and support the recruiting of parents and children?

( ) Yes

( ) No

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.

Teacher Informed Consent Form

STUDY TITLE: Formative Research for MyPlate Elementary School Lesson Plans

PROTOCOL NUMBER: 231G

PRINCIPAL INVESTIGATOR:	Michael Cohen, Ph.D.
TELEPHONE:	212-431-2252
ADDRESS:	Michael Cohen Group LLC 375 West Broadway, Suite 502 New York, NY 10012

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 nutrition lessons for 1^st-6^th grade children. Michael Cohen Group is an international research and consulting firm that specializes in children, education and media.

We are currently working with a firm called JMH Education to help develop an effective and easy-to-use nutrition curriculum for 1^st-6^th grade children, based on the 2010 Dietary Guidelines for Americans and MyPlate. If you agree to participate, you will be asked to conduct three nutrition lessons and keep a journal about your experiences with each lesson. You will also be asked to participate in a telephone interview at the conclusion of those lessons. We are interested in the opinions of 1^st-6^th grade teachers concerning the ease of use of the lessons, children’s response to lessons and about nutrition education generally. You will be asked questions about these topics.

PROCEDURES:

As part of this research project, you will be asked to distribute and collect a brief survey to students about MyPlate and nutritious food choices. You will also be asked to provide feedback on teaching your students about MyPlate as part of your normal classroom curriculum By completing an educator’s journal and participating in a one-on-one phone interview . The interview will last 45 minutes. Additionally, you will be responsible for distributing and collecting consent forms to parents for children’s participation in the research.

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.

STIPEND:

At the end of the research activities, you will receive a $50 cash stipend as a token of appreciation.

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. Your name will not be divulged in any reports of this research.

The research will not be used in any advertising. All data will be identified only by an ID number, not by any name. The research may be audiotaped for research purposes only. Any audio collected as part of the research will be destroyed once the study analysis is complete. Your name will never be used in any documentation of our research findings. Your comments, voice, or image will never appear in public without your written consent.

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.

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