FFVP CFD Pilot - Individual

Evaluation of the Canned, Frozen, or Dried Fruits and Vegetables Pilot Project in the FFVP

Appendix E3a Administration Script – Assent and Survey – Student

OMB Control No: 0584-XXXX

Expiration date: XX/XX/XXXX

SURVEY ADMINISTRATOR INTRODUCTION, SAY:

Hello everyone, I am _____________and I will be conducting a study for the US Department of Agriculture Food and Nutrition Service about the fruit and vegetable snacks at your school. Today I will ask you to take a survey about the food you eat during the school day. Some of you may be asked to meet with an interviewer to talk about specific foods you ate during a school day. All students who participate in the study will receive a small gift.

ASSENT (PERMISSION) FORM: DISTRIBUTED PRIOR TO STUDENT ARRIVAL OR DISTRIBUTED AFTER STUDENTS ARE SITTING. SAY:

Look at the permission form in front of you. It is the yellow sheet of paper. I will read the form aloud and you can follow along with me.

READ FROM ASSENT FORM:

Dear Student:

We would like to learn more about the foods at your school, which ones you like and don’t like, and what you think about the fruit and vegetable snacks at school.

We are asking students in a few classrooms to fill out a short survey about fruits and vegetables they eat during the school day. This is voluntary.

We will also ask a few students to fill out a simple food diary and be interviewed about foods they eat in school. This is also voluntary.

If you decide not to take part in the study, nothing will happen to you. Your parents know that you might take part in this study.

Please print and write your name below if you would like to take part in the study.

Then place this form on the top right corner of your desk. Then please complete the survey. The survey will take you about 10 minutes to complete.

If you do not want to take part in the study, do not print or write your name on the form or complete the survey.

STOP

According to the Paperwork Reduction Act of 1995, an agency may not conduct or sponsor, and a person is not required to respond to, a collection of information unless it displays a valid OMB control number. The valid OMB control number for this information collection is 0584-XXXX. The time required to complete this information collection is estimated to average 5 minutes for the assent form and 15 minutes per response for the survey, including the time for reviewing instructions, searching existing data sources, gathering and maintaining the data needed, and completing and reviewing the collection of information.

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