FFVP-CFD_Appendix_E1b1_Parent_Consent_Active_Eng

LETTER TO:

FROM:

DATE:

PAGE: 0

Rhoda Cohen P.O. Box 2393

Senior Survey Researcher and Princeton, NJ 08543-2393

Survey Director for the FFVP-CFD Study Telephone (609) 799-3535

Fax (609) 799-0005

www.mathematica-mpr.com

(800) 232-8024

OMB Control No: 0584-XXXX

Expiration date: XX/XX/XXXX

Fall 2014

Parent/Guardian of: <StudentFirstName> <StudentLastName>

Student of <TeacherLastName><TeacherFirstInitial>

<ClassRoomName>

<School>

Dear Parent:

Your child’s school and school district are participating in a study of the Fresh Fruit and Vegetable Program, funded by the U.S. Department of Agriculture’s Food and Nutrition Service, that is taking place in elementary schools across the country. Your school and district have given Mathematica Policy Research permission to conduct this study, and we are asking for your permission to include your child in the study.

If your child participates in the study, he or she will be asked to complete a brief survey about how well he or she likes the fruit and vegetable snacks offered at school. Some students will be asked to complete a food diary of what they ate during a school day and a short dietary interview. Students completing the food diary and dietary interview during school hours will receive a $5 gift card. The data will be analyzed by the study team to learn about your school’s fruit and vegetable snacks, but no information that directly identifies your child will be shared outside the study team.

Please read the next page to learn about the study and the diary and survey that we would like you and your child to complete.

• Filling out the student diary and survey are voluntary. There will not be any penalties for you or your child if you decide not to allow your child to be in the study.

• If you have any questions about the study, please call my staff toll-free at (800) 232-8024 or email us at [email protected].

• If you agree to allow you and your child to be in the study, check the YES box and sign. If you do not agree to allow your child to participate in the study, check the NO box and sign. Return the signed form below in the business reply envelope provided.

Thank you.

Rhoda Cohen

PARENT PERMISSION FORM

I have read the information about this study and understand that I am being asked to allow my child to participate in a study focused on the eating of fruits and vegetable program.

MARK  ONLY ONE BOX
	YES, I will ALLOW my child to participate in the study about eating fruits and vegetables during the school day by completing a food diary and a short survey.	________________ Parent Signature	___/___/____ MM / DD / YYYY
OR
	NO, I will NOT ALLOW my child to participate in the study about eating fruits and vegetables during the school day by completing a food diary and a short survey.	________________ Parent Signature	___/___/____ MM / DD / YYYY

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 10 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.

Information about the Study for Parents and Students

What is the Purpose of the Study?

As mandated by Congress, the U.S. Department of Agriculture’s (USDA) Food and Nutrition Service (FNS) is funding a study to learn how schools’ implementation of the Fresh Fruit and Vegetable Program affects students’ diets and satisfaction with the free fruit and vegetable snacks. The USDA FNS has contracted Mathematica Policy Research, an independent research firm, to conduct the study.

What does it mean to participate in the study?

Students will be asked to fill out a short diary to keep track of the foods they eat in school for one day. We will choose up to 12 students per classroom to fill out the food diary. If chosen, each student will be given instructions orally and in writing by a member of the Mathematica study team on how to fill out the food diary for all foods eaten during the school day.

Also, students will be asked to complete a brief survey that will ask some questions about themselves and about how often they eat the free fruit and vegetable snacks offered at school what they like or dislike about them. The student interview will take about 20 minutes to complete. Mathematica staff will also observe the distribution of fruit and vegetable snacks during the school day.

Parents will be asked to answer some brief questions about the free fruit and vegetable snacks provided at school and what they like or dislike about the program. The parent questionnaire will take no more than 10 minutes to complete. Parents will receive a $5 gift card for completing and returning the brief survey. Students that completed diaries will receive a $5 gift card as reimbursement for the time associated with being in the study. A small number of students will be asked to record their food and beverage intake for a second day and be given another $5 gift card for a completed food diary/dietary interview.

What are the Risks and Benefits?

Completing the questionnaires is voluntary. There are no penalties for refusing to participate. Students are not required to be in the study in order to continue to be in any school program. Being part of this study will not hurt students or parents in any way. If any parent or student feels uncomfortable at any time during the study, they may decide not to participate.

Will it be Confidential?

Mathematica has strict procedures to store data securely and to ensure the confidentiality of the names of students and parents by removing names before data are analyzed. Names will not be written in any report or given to anyone other than the study team. Teachers, school staff, program staff and parents will not be allowed to see any of the information from the questionnaires.

What if I Have Questions? If you have any questions about the study, please contact Rhoda Cohen, Mathematica Survey Director or her staff at (800) 232-8024 or email at [email protected].

*****************************************

We would like your permission for your child and you to fill the study questionnaires and ask that you complete and sign the Parent Permission form (found on the other side of this paper).