Team Nutrition Educational Materials for Summer Meals

OMB Control # 0584-0524 | Expiration: 06/30/2016 |Page 5

Attachment B: Consent Form for Parents/Caregivers (English and Spanish)

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 including time to complete and review the information collection.

Parent/Caregiver Letter

[DATE], 2015

Dear Parent/Caregiver,

The Food and Nutrition Service of the United States Department of Agriculture (USDA) is working to develop materials for parents and caregivers about healthy food choices and being physically active during the summer months. We are interested in getting feedback from parents/caregivers about these materials so the final products are relevant, meaningful, and fun. To this end, we will be conducting focus groups with parents/caregivers.

Included with this letter you will find consent forms with additional information. If you would like to participate in the parent/caregiver focus group interviews please complete page 4 and keep the remaining pages for your files.

If chosen to participate in the parent/caregiver focus group interview, you will receive $50 as a token of our appreciation.

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

[ Researcher’s Name]

Consent Form for Parent/Caregiver Focus Group

STUDY TITLE: Team Nutrition Educational Materials for Summer

PROTOCOL NUMBER: Chesapeake IRB# XXXXXX

PRINCIPAL INVESTIGATOR: Gerad O’Shea

Michael Cohen Group

TELEPHONE: 1-212-431-2252

ADDRESS: 375 West Broadway, Suite 502

New York, NY 10012

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 including time to complete and review the information collection.

BACKGROUND AND PURPOSE:

You are invited to participate in a research study conducted by the Michael Cohen Group (MCG) as part of the Food and Nutrition Service of the US Department of Agriculture’s sponsored effort to develop materials for parents about family nutrition and healthy activity. MCG is an international research firm that specializes in children, education, and media.

MCG is currently working with parents/caregivers across the country to develop materials on family nutrition solutions and healthy activities for the summer months. Interested parents will participate in focus group interviews. If you participate, you will be asked questions about 1) a draft version of the parent materials and 2) about health and nutrition in general.

PROCEDURES:

As part of this research project, you will participate in a 90-minute focus group interview about nutrition and children’s physical activity during the summer months. The interview will be conducted in a group setting with other parents/caregivers of children similar in age as your own. A total of 80 parents will participate across two regions of the United States. The interview will be audio-recorded or videotaped for internal research purposes only.

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 direct benefits from this study. However, we do anticipate that most people will enjoy participating in the research process, and the result of the research will be a free resource for all parents and caregivers.

STIPEND:

At the end of the research activities, you will receive $50 for your participation

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, addresses, and phone numbers will only be used to contact you about this research activity. They will not be divulged in any reports of this research or given to anyone else for other purposes unless otherwise required by law. ID numbers will be used to identify all data, without using any names. 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:

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. 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