M3. Student Assent Form

M3. STUDENT ASSENT FORM

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OMB Clearance Number: 0584-xxxx

Expiration Date: xx/xx/xxxx

chool Nutrition and Meal Cost Study

Student Assent

Who is conducting the study? The study is for the U.S. Department of Agriculture. This is the part of the federal government that is responsible for school meal programs. Mathematica Policy Research is a research company that was hired to collect all the information for the study.

Do I have to participate in the study? No. You can decide if you want to be in the study or not.

Will anyone know I am in the study? No. Your name will not be part of the study, and your answers will be kept private.

Will my answers be kept private? Yes. All information gathered for the study is private to the full extent allowed by law. The person who will interview you is not allowed to share your personal information with anyone except other people working on this study. Your name will not be part of the study.

What if I do not eat school meals? Even if you do not eat the school breakfast or lunch, we still want you to be in the study. It is important for the study to learn about both students who eat school meals and students who do not.

Who can I talk to about the study? If you or your parents have any questions about the study, you can call Mathematica toll free at 1-888-xxx-xxxx. [SCHOOL LIAISON] at your school is also working directly with the study team and can answer questions. That person’s phone number is xxx-xxxx.

Your parent(s)/guardian(s) received a letter and brochure that explains what we are asking you to do. They can contact Mathematica at any time if they do not want to give permission for you to participate or if they have any questions about it.

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-XXXX. The time required to complete this information collection is estimated to average 3 minutes per response, including the time to review instructions, search existing data resources, gather the data needed, and complete and review the information collection.

It is your decision to participate in the study. We can explain more about how everything will work to help you make that decision. Please tell us at any time if you decide not to participate. You are always free to change your mind.