Appendix E.11 Child Assent

OMB Control No: 0584-0606

Expiration Date: 03/31/2019

Appendix E-11.

Child (5-12 yrs) Assent to Participate in the

Summer Meals Study Pretest

Hello, my name is ______________ and I work for Westat. Westat is a company that does research by asking people questions and listening to what they say. We are calling on behalf of the United States Department of Agriculture (USDA), Food and Nutrition Service (FNS). FNS is a part of the government that helps give food to children in the summertime when there’s no school. Today, I have some questions to ask you about meals served at summer programs].

So today, I’d like to spend about 30 minutes talking with you about the food you get at [NAME OF SITE].

First, I will give you a piece of paper with some questions on it [COMPLETED WITH PARENTAL SUPPORT IF CHILD VERY YOUNG]. Then I will ask you what you think of those questions. We are asking lots of kids about the food they get at summer programs. Your answers, and all the other kid’s answers, will help make the questions better for everyone.

Does that sound okay?

IF YES: Some other people working with me are sitting behind that mirror [POINT TO MIRROR]. That’s a special mirror. They can see us but we can’t see them. They are there because they are interested in hearing for themselves what you think. Only me and the people I work with on this research will know what you say and we will not tell anybody else.

You don’t have to talk to me today if you don’t want to. If we start and then you decide you want to stop, that’s okay too. Just tell me if you want to stop.

If it’s okay, I would also like to record what we talk about today on this device [SHOW HAND HELD AUDIO RECORDER]. This helps me pay attention to what you say while we talk rather than write notes. Then I can still listen to the recording later to remember exactly what you said. We will not keep this recording for very long. After we have talked to all the kids in this study, I will delete this recording.

Are there any questions you would like to ask me right now?

You can still ask me questions at any time, okay?

It is okay for me to talk with you?

Is it okay if I record what we say today? If you don’t want me to, I won’t. It’s completely up to you.

We are ready to start now.

INTERVIEWER MARK IF CHILD AGREES TO INTERVIEW:

• Yes

• No

INTERVIEWER MARK IF CHILD AGREES TO RECORDING:

• Yes

• No

Interviewer name:______________________________

Interviewer signature:___________________________

Date:_________________________________

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.