SLT agencies Principals-Teachers-School Nutrition Directors

Site: ______________________________ OMB Control # 0584-0523

Date: _____________________________ Expiration Date: 01/31/2016

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Attachment C – School Nutrition Director Letter, Survey for Participation in Individual Interviews and Informed Consent Form (School Nutrition Director Consent Package)

[DATE], 2013

Dear School Nutrition Director,

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 will be working with two kindergarten classes at your school to get feedback on nutrition education lessons that are being developed by the United States Department of Agriculture (USDA). We are interested in getting feedback from you about specific lessons that relate to school nutrition services and the school meals programs.

The six Discover MyPlate lessons include a variety of activities designed to teach children about making healthy food choices and being physically active. It also includes take-home materials for parents. Within each lesson are specific “Cafeteria Connections” so that children may apply what they are learning in class to school lunch and beakfast. There are also four simple food preparation activities, which would benefit from collaboration with school nutrition services.

If you agree to participate, you will be asked to collaborate with the kindergarten teachers at your elementary school on these lesson activities and take part in a 30-minute interview about your experience.

If you chose to participate, you will receive $50 as a token of appreciation. The school will also receive $350, which can be used to help cover the cost of food and supplies for the class food preparation activities.

Included with this letter you will find a consent form with additional information. If you would like to collaborate with the two kindergarten teachers and participate in the brief phone interview, 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 0584-0523. 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.

Informed Consent Form for School Nutrition Director

STUDY TITLE: Pilot Research for MyPlate Kindergarten Materials

PROTOCOL NUMBER: 251G

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 (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 collaborate with the two teachers conducting the curriculum at their school and asked questions about your experience with materials and activities.

PROCEDURES:

As part of this research project, you will be asked to collaborate with teachers on how to best implement the food preparation activities in the curriculum as well as other curriculum experiences related to the school cafeteria, with consideration of Federal/State, school, and local health department policies and school resources. You will be asked to participate in a phone interview about the curriculum materials and activities, your experience working with the kindergarten classes, and how best to foster collaborations between classroom teachers and school nutrition staff. 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 $50 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 will be audiotaped for research purposes only. Your name will not 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]

Informed Consent for School Nutrition Director 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)

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