Appendix I5 Parents Informed Consent

OMB Control No.:0584-NEW

Expiration Date: xx/xx/xxxx

Public reporting burden for this collection of information is estimated to average xx 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. An agency may not conduct or sponsor, and a person is not required to respond to, a collection of information unless it displays a currently valid OMB control number. Send comments regarding this burden estimate or any other aspect of this collection of information, including suggestions for reducing this burden, to: U.S. Department of Agriculture, Food and Nutrition Services, Office of Policy Support, 3101 Park Center Drive, Room 1014, Alexandria, VA 22302 ATTN: PRA (0584-xxxx*). Do not return the completed form to this address.

APPENDIX 1-5 PARENTS INFORMED CONSENT

Summer Food Service Program Participant Characteristics Study

Parent/Caregiver Informed Consent Form

You may be qualified to participate in the United States Department of Agriculture (USDA) Food and Nutrition Service (FNS) study on Summer Food Service Program (SFSP) participation. Please read the information below to learn about the study and your role, and feel free to ask questions. Before you participate in the interview, please sign your name at the bottom of this form and send it back to us, Optimal Solutions Group (Optimal); see the letter provided in your recruitment packet for instructions. Please keep the second copy of this form for yourself. In return for your participation in this study, we will provide you with a $25 prepaid VISA gift card as a token of our appreciation. Thank you for your interest in our study.

What is this study and what will you ask me to do?

The goals of this study are to learn the reasons why parents/caregivers did or did not have their children participate in the SFSP, how often their children attend SFSP sites, what could be done to improve their attendance, and whether/how they heard about the program. Near the end of the summer, you might be asked to participate in a one-on-one conversation with a member of the research team while another team member takes notes.

What is the time required to participate in this project?

We expect that it will take about 30 minutes to complete the interview over the phone.

Will my answers be confidential?

Your individual answers will be kept private. Your name will never be used in any reports related to this study, and your individual answers will not be reported back to any member of the school district or the USDA. All the information that you provide will be kept private from everyone outside our research team, except as otherwise required by law.

Do I have to participate in this project?

Your participation in this study is completely voluntary. You have the right to stop participating at any time, and you do not have to answer any questions that you do not want to. You have the right to not participate, to not answer specific questions, or to withdraw from the study without penalty.

Who is conducting this project?

This project is being conducted by a research organization called Optimal Solutions Group (Optimal) under contract to the USDA.

What if I want more information?

If you have questions or concerns about this research study, please contact Optimal at 877-776-8501 or [email protected].

For more information about the SFSP, please visit www.fns.usda.gov/sfsp/summer-food-service-program-sfsp

Please sign below if you agree to participate.

By signing below, you are giving your “informed consent” to participate in our study. This means that you have read and understand the information in this form, that you have had a chance to ask questions, and that you are willing to participate under the conditions we have described.

Participant signature: ____________________________________ Date: __________________________

Participant name (print): __________________________________