Parent/Student REV 2

Site: ______________________________ OMB Control # 0584-0524

Date: _____________________________ Expiration Date: 04/30/2013

Attachment B – Parent/Caregiver Letter

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 15 minutes for the screener, including the time for reviewing instructions and completing the information.

[DATE], 2012

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 (USDA). As part of your child’s normal classroom instruction, we are piloting a curriculum for 5^th and 6^th grades that teaches children about healthy eating through gardening and classroom lessons in a way that also meets science, math and English/language arts requirements.

To help inform the development of the curriculum, we are requesting your consent to have your child complete short surveys in class, before and after the unit is taught. We are also interested in getting parent feedback on the curriculum’s “at home” components.

For your participation in this study, you will receive $20 as a token of our appreciation.

Included with this letter you will find consent forms, a brief survey and additional information. If your child wishes to participate, please complete the parent consent for child participation form. If you would be willing to participate in a brief telephone interview after your child completes the lessons, please complete the parent consent form.

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

[Researcher’s Name]

Attachment B – Parent/Caregiver Survey for Participation

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 15 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.

1. Are you the parent or guardian of any children in the 5^th or 6^th grade who live at home with you?

( ) yes

( ) no

2. Please indicate the ages and gender of all children who are in the 5^th or 6^th grade living at home with you.

Age 9 ( ) boy / ( ) girl

Age 10 ( ) boy / ( ) girl

Age 11 ( ) boy / ( ) girl

Age 12 ( ) boy / ( ) girl

3. Ethnicity

( ) Hispanic or Latino

( ) Not Hispanic or Latino

4. Race (select one or more)

( ) American Indian or Alaskan Native

( ) Asian

( ) Black or African American

( ) Native Hawaiian or Other Pacific Islander

( ) White

5. 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

6. 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

Attachment B – Parent/Caregiver Informed Consent Form

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 15 minutes for the screener, including the time for reviewing instructions and completing the information.

STUDY TITLE: Project JMH Gardening: Formative Curriculum 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

BACKGROUND AND PURPOSE:

We are currently working with your child’s school to pilot a curriculum for 5^th and 6^th grade children that teaches children about healthy eating through gardening and classroom lessons.

PROCEDURES:

As part of this research project, you may be asked to participate in a phone interview about your child’s experience in the nutrition lessons and your experiences with the take home materials. The interview will last about 20 minutes. About 18 parents will participate in total.

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 $20 as a token of our 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. 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.

Attachment B – Parent/Caregiver Informed Consent Form for Student

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 15 minutes for the screener, including the time for reviewing instructions and completing the information.

STUDY TITLE: Project JMH Gardening: Formative Curriculum 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

BACKGROUND AND PURPOSE:

We are currently working with your child’s school to pilot nutrition lessons for 5^th and 6^th grade students to encourage life-long appreciation for fruits and vegetables.

PROCEDURES:

As part of this research project, a brief survey will be handed out by your child’s teacher both before and after the nutrition lessons. Your child will complete the survey during class time and give the completed survey back to their teacher. All of the questions will be on nutrition-based topics. Your child’s entire class is being asked to participate in the nutrition lessons as part of their regular curriculum.

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, your child’s school will receive $500.

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. 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 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.