MyPlate

Site: ______________________________ OMB Control # 0584-0524

Date: _____________________________ Expiration Date: 04/30/2013

Attachment C – Food Service Staff 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 School Food Service Representative,

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 grades 1-6 and discussing how they connect to school meals and food choices.

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 school food service is critical to ensuring that these lessons are educational, relevant for children and connect to shool meals and food choices.

Included with this letter you will find a consent form with additional information. If you would like to participate in the brief phone interview regarding MyPlate, please complete the consent form 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.

Informed Consent Form for Staff

STUDY TITLE: Formative Research for MyPlate Elementary School Lesson Plans

PROTOCOL NUMBER: 231G

PRINCIPAL INVESTIGATOR:	Michael Cohen, Ph.D.
TELEPHONE:	212-431-2252
ADDRESS:	SoHo Research Centre 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 lesson plans 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 lesson plans for 1^st-6^th grade children based on the MyPlate.gov suggestions for healthy eating that will be easily integrated into school meals and fodd choices. If you participate, you will be asked questions about your experience with the MyPlate lessons and the role of nutrition education in the school.

PROCEDURES:

As part of this research project, you will be asked to participate in a phone interview about nutrition at your school. The interview will last about 45 minutes.

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 stipend of $25 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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