SLT agencies Principals-Teachers-School Nutrition Directors

OMB Control # 0584-0523

Expiration Date: 1/31/2016

Attachment A – Teacher Letter, Survey for Participation in Research and Curriculum Activities, and Informed Consent Form (Teacher Consent Package)

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 0584-0523. The time required to complete this information collection is estimated to average 10 minutes response, including time to review instructions, search existing data resources, gather the data needed, and complete and review the information collection.

[DATE], 2013

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 child’s school to develop nutritional lessons and materials for kindergarten students. The United States Department of Agriculture (USDA) is sponsoring this effort. We are interested in getting feedback from teachers about these materials.

Specifically, the lessons are based on the MyPlate guidelines for making healthy food decisions and will include six classroom lessons expected to take a combine total of 12 hours to teach. It is important for us to get teacher feedback so the final products are relevant, meaningful and easy-to-use. To this end, we are looking for teachers to use the kindergarten curriculum and provide feedback about their experiences. We also need teachers to help recruit parents/caregivers and students so that we might get their feedback on lesson materials as well. Specifically, you would be responsible for:

1. Distributing packets (containing the letter of invitation, parent/caregiver 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 six Discover MyPlate Kindergarten lessons, including four simple food preparation activities as part of your class instruction Completing an educator journal to record your experiences and feedback about the completed activities

5. Participating in a 30-minute telephone interview about your experience with the curriculum

If you chose to participate, you will receive $200 as a token of 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.

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 0584-0523. The time required to complete this information collection is estimated to average 10 minutes response, including time to review instructions, search existing data resources, gather the data needed, and complete and review the information collection.

Teacher Survey for Research and Curriculum Activities

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

1. How many students are in your class? ____________________

2. Is the Kindergarten program at your school full or half day? _______________

3. Do kindergarteners eat lunch at your school? Yes / No

4. Do students have the option to eat breakfast at your school? Yes / No

5. Have you conducted food preparation activities in your classroom? Yes / No

6. How many years have you been teaching?

( ) First year

( ) 2-5 years

( ) 5-10 years

( ) Over 10 years

7. Ethnicity

( ) Hispanic or Latino

( ) Not Hispanic or Latino

8. Race (select one or more)

( ) American Indian or Alaskan Native

( ) Asian

( ) Black or African American

( ) Native Hawaiian or Other Pacific Islander

( ) White

9. What is your current age?

( ) Under 20

( ) 20-29

( ) 30-39

( ) 40-49

( ) 50+

10. What is your gender?

( ) Female

( ) Male

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 0584-0523. The time required to complete this information collection is estimated to average 10 minutes response, including time to review instructions, search existing data resources, gather the data needed, and complete and review the information collection.

Teacher Informed Consent for Research and Curriculum Activities

STUDY TITLE: Pilot Research for MyPlate Kindergarten Curriculum Materials

PROTOCOL NUMBER: 251G

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 (MCG) as part of a United States Department of Agriculture (USDA) sponsored effort to develop nutrition lessons for kindergarten children. MCG is an international research firm that specializes in children, education and media.

We are working to help develop nutrition lessons that include activities, a song, a poster, a story, and a parent handout that teach children about making healthy food choices, the five food groups, and MyPlate. If you participate, you will be asked to teach the curriculum and provide feedback about your experience.

PROCEDURES:

As part of this research project, you will be asked to conduct the six-lesson curriculum with your kindergarten class. Each of the six lessons is comprised of 6-10 activities. You will also be asked to complete a one-on-one telephone interview about your experience conducting the curriculum as well as an educator journal. The interview will last about 30 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 $200 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 name, addresses, and phone numbers will only be used to contact you about this research activity. They will not be given to anyone else for other purposes. The research interviews will be audiotaped for research purposes only. Your name will never be used in any reports of our research findings. Your information will be kept secure and only used for research purposes, except as otherwise required by law. All data will be identified only by an ID number, not by any name.

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]

Teacher Informed Consent Form

Please complete the section below if you agree to participate and return it to your principal. Please keep the previous pages for your records.

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

____________________________________________

Phone (for research purposes only)

____________________________________________

Email Address (for research purposes only)