WIC Participant

OMB Approval No. 0584-0580

Approval Expires: XX/XX/20XX

Site Name and #

Appendix C.1

Age 3 Extension Infant and Toddler Feeding Practices Study - II

Consent Form & Contact Information - English

Feeding My Baby - A National WIC Study

Age 3 Study Extension Consent Form

Background

Westat, along with our partners at University of California Los Angeles, Altarum Institute, and University of California Berkeley, is carrying out The Feeding My Baby Study for the Food and Nutrition Service (FNS) of the U.S. Department of Agriculture. The study is being done to learn more about the choices WIC families make in feeding their children. FNS has extended the study by 1 year to follow children enrolled in the study until the age of 3. We would like you to help by agreeing to participate in the study until your child is 3 years old, and allowing us to hear more about you, your family, and the choices you make in feeding your child.

What Would I Do in the Study?

Take Part in Telephone Interviews

If you agree to participate in the extension of this study we will contact you when your child is 2½ years old and 3 years old. The interviews will ask you about your background, your household, your experiences in WIC, your health and your child’s health, the choices you make about how and what to feed your baby, your beliefs and advice you’ve gotten about feeding babies and toddlers, and your family’s and child’s behavior and habits. Each interview will take about thirty minutes.

Allow Us to Seek WIC Records

We will, with your permission, seek WIC record information about your child when your child is 3 years old. This will include information on the food packages WIC gives your child, and your child’s weight and length. If we lose touch with you, we might also ask WIC for information on how to contact you.

Allow Us to Seek Information on Your Toddler’s Length and Weight

If your child is no longer receiving WIC at age 3, we may ask you to return to the WIC office to have your child weighed and measured. If you cannot return to the WIC office, we will, with your permission, seek information about your child’s height and weight from your child’s medical provider.

What Are the Risks of Being In This Study?

We expect that your time in the study will be interesting and pleasant, and will not cause you discomfort. There is, however, a small risk to privacy since you are entrusting us with personal information. We will continue to take many steps and precautions to protect your privacy. Your name and your child’s name will not be used in any research reports. We will assign a study ID to your information, and only a small number of study staff will have access to the connection between study IDs and actual names. All study information will be stored on secure computer servers at Westat. We will not share personal information about you with WIC or with anyone else who is not on the study staff, unless otherwise required by law.

What Are the Benefits of Being In This Study?

There are no direct benefits or penalties to you for taking part in this study. The information collected during the study will help the FNS understand better how WIC mothers choose to feed their children, and how WIC services help mothers with those choices. They will then use this information to continue to improve WIC services for everyone.

As a token of our appreciation, we will provide you with a cash incentive of $30 (or $40 if you are using your own cell phone to completed the interview) for the 2½ year-old interview and $40 for the 3 year-old interview (or $50 if you are using your own cell phone), added to your study debit card. We will provide you with a $30 incentive for taking your child to the WIC office to be measured if your child is no longer enrolled in WIC at age 3.

What Are My Rights As a Participant In the Study?

Taking part in this study is completely voluntary. Giving consent means that you have read the information about this study and that you agree to take part. You may still decide not to answer any questions we ask that you don’t want to answer. If you decide not to take part in an interview, we will continue to get records from WIC on your child’s food package and height and weight for the rest of the study period unless you tell us to stop that as well. If you decide to take part in the study and then change your mind, you can stop at any time. Again, there is no penalty to stop participatingin whole or in part in the study, and it won’t affect any WIC services or other benefits you otherwise get.

Who Should I Call if I Have Questions?

If you have questions about the study itself and what we are doing, a member of our study team can help you. For those questions, please contact [STUDY LIAISON] at 888-888-8888.

If you have a problem that the study team member couldn’t help you resolve, please call Dr. Nancy Weinfield at 1-800-937-8281, x. 2480.

If you have questions about your rights and welfare as a research participant, please call the Westat Human Subjects Protections office at 1-888-920-7631. Please leave a message with your full name, the name of the research study that you are calling about (the Feeding My Baby Study), and a phone number beginning with the area code. Someone will return your call as soon as possible.

By signing below, I am saying that I have read the information presented here, and I agree to take part in the extension of the Feeding My Baby Study, and to allow the study to seek WIC record information about my child.

Signature

Date

	Keep in touch with Feeding My Baby!
PLEASE HELP US STAY IN TOUCH BY UPDATING YOUR CONTACT INFORMATION BELOW AND MAILING IT BACK TO US IN THE ENCLOSED ENVELOPE.

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YOU WILL RECEIVE $5 ON YOUR PAYONEER CARD FOR RETURNING THE COMPLETED FORM.

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YOUR NAME

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STREET ADDRESS

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CITY STATE ZIPCODE

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PHONE

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CELL PHONE

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CAN WE TEXT YOU?  YES  NO

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EMAIL

PLEASE TELL US THE NAME AND CONTACT INFORMATION OF 2 PEOPLE WHO ALWAYS KNOW HOW TO FIND YOU:

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NAME

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STREET ADDRESS

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CITY STATE ZIPCODE

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PHONE

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CELL PHONE

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EMAIL

#2. ____________________________________________________

NAME

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STREET ADDRESS

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CITY STATE ZIPCODE

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PHONE

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CELL PHONE

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EMAIL

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 number.  The valid OMB control number for this information collection is 0584-0580.  The time required to complete this information collection is estimated to average 8 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.