Appendix E.5 Parental and 18 Year Old Consent Revised

OMB Control No: 0584-0606

Expiration Date: 03/31/2019

Appendix E-5.

Parent/Caregiver [and 18-Year-Old Teen] Consent to Answer Questions

to be used in the Summer Meals Study

You are being asked to take part in a voluntary research study conducted by the U.S. Department of Agriculture (USDA) Food and Nutrition Services (FNS). The study is to help us test questions which will be included in a survey about the Summer Meals Programs. These programs provide meals and snacks to children in low-income areas during the summer months when school is not in session. The findings from talking to you will help us to improve these questions.

The interview will last about [an hour/30 minutes]. You will receive {$50/$40/$30} to reimburse you for any expenses you incurred for transportation [or child care].

Your participation in this study is voluntary. You may choose not to answer any question, and you can stop this interview at any time. There are no penalties if you choose to not participate.

Project staff from the Food and Nutrition Service and from Westat may be observing this interview so they hear your comments about the survey questions.

There are no known risks to you for taking part in this interview. All the data we collect will be kept private. You will not be identified by name in any of our summaries or reports, and your name will not be shared with anyone outside this study, except as otherwise required by law. Your name will not be linked to any of your responses. We may include quotes you provide in our reports. Your information will be combined with information from other respondents and presented in summary form. There are also no direct benefits to you for taking part in this interview, but your answers will help us to develop recommendations for improving the survey questions.

With your permission, I will audio-record the interview. This is in case I missed something in my notes. The recording and all study materials that identify you will be destroyed by the end of the project.

If you have any questions about this study, please call [NAME] at [PHONE NUMBER].

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 “SUMMER MEALS STUDY”, and a phone number beginning with the area code. Someone will return your call as soon as possible.

I have read the information above and:

• I agree to participate in the interview.

• I agree to have my interview audio-recorded.

Signature: ___________________________________________ Date: _________

Print Name: __________________________________________

Name of Researcher: _______________________________

Public reporting burden for this collection of information 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. 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.