FFVP-CFD_Appendix_E3b1_Student_Assent_Eng

Evaluation of the Canned, Frozen, or Dried Fruits and Vegetables Pilot Project in the FFVP

Appendix E.3b1. Assent – Student (English)

Rhoda Cohen P.O. Box 2393

Senior Survey Researcher and Princeton, NJ 08543-2393

Survey Director for the FFVP-CFD Study Telephone (609) 799-3535

Fax (609) 799-0005

www.mathematica-mpr.com

(800) 232 8024

OMB Control No: 0584-XXXX

Expiration date: XX/XX/XXXX

Fall 2014

Student: <StudentFirstName> <StudentLastName>

Student of <TeacherLastName><TeacherFirstInitial>

<Classroom Name>

<School>

Dear Student:

We would like to learn more about the foods at your school, which ones you like and don’t like, and what you think about the fruit and vegetable snacks at school.

We are asking students in a few classrooms to fill out a short survey about fruits and vegetables they eat during the school day. This is voluntary.

We will also ask a few students to fill out a simple food diary and be interviewed about food they eat in school. This is also voluntary.

If you decide not to take part in the study, nothing will happen to you. Your parents know that you might take part in this study.

Please print and write your name below if you would like to take part in the study. If you do not want to take part, do not print or write your name.

Thank you.

Rhoda Cohen

PRINT STUDENT NAME: _____________________________________________

STUDENT SIGNATURE: ______________________________________________

According to the Paperwork Reduction Act of 1995, an agency may not conduct or sponsor, and a person is not 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 5 minutes per response, including the time for reviewing instructions, searching existing data sources, gathering and maintaining the data needed, and completing and reviewing the collection of information.

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E.3b1.1