Appendix E.12 Teen Assent

OMB Control No: 0584-0606

Expiration Date: 03/31/2019

Appendix E-12. Teen (13-17 yrs) Assent to participate in the

Summer Meals Study Pretest

You are being asked to take part in a research study conducted by the U.S. Department of Agriculture (USDA) Food and Nutrition Service (FNS). This study is to help us test questions which will be included in a survey of Teens about the Summer Meals Programs. The Summer Meals Programs provide meals during the summer months, when school is out.

This form tells you about the study and what you will be asked to do. If you choose to take part, you will need to sign this form.

The study is voluntary. You can choose if you want to take part in this interview or not, even if your parents or legal guardian gave their permission. You may choose not to answer any question, and can stop the interview at any time. Your answers will not be shared with your parents. If you agree to take part, I will ask you questions from the Teen survey and what you think about the questions. Talking to you will help us to improve the questions.

I will talk with you for about 45 minutes. You will receive $30 as a token of appreciation.

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

Being part of this study may not help you, but you will be helping with an important research study. There are no known risks to you taking part in this interview. All the data we collect will be kept private and will not be disclosed to anyone outside of the research team, except as otherwise required by law. You will not be identified by name in any of our summaries or reports. Your name will not be linked to any of your responses, though we may include quotes you provide in our reports. Your information will be combined with information from other teens and presented in summary form.

With your permission, your interview today will be audio-recorded. This is in case the interviewer misses something in their notes. The recording will be destroyed by the end of the project.

If you have any questions about this study please ask the interviewer now. You can also 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 the “TEEN SUMMER FOOD 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.