D3a_EDECH final active consent letter 2015.8.17

Evaluation of Demonstration Projects to End Childhood Hunger (EDECH)

ATTACHMENT D.3.a. ACTIVE CONSENT FOR HOUSEHOLD SURVEY (ENGLISH)

Fall 2015

Dear [PARENT/GUARDIAN],

[GRANTEE AGENCY] is running a new project called the [DEMONSTRATION PROJECT]. The U.S. Department of Agriculture (USDA) funds [DEMONSTRATION PROJECT] and others like it. USDA wants to learn about how these projects help families provide food for their children. Mathematica Policy Research is studying the projects for USDA. We are asking your household to be in the study.

If you agree to be in the study, we will ask you to complete [two/three] 30 to 35-minute phone surveys. The surveys are about your household’s experiences related to food. [One survey will be this year and one will be a year from now./One survey will be this year, one will be a year from now, and one will be a year and a half from now.] We will send you a letter that explains how to do the survey when the study starts. We will send you $30 as a thank you for completing the survey. We will also collect data about you from [DEMONSTRATION PROJECT]. The data will include information such as the benefits you may receive. We will use the data to describe the effect that [DEMONSTRATION PROJECT] and others like it have on households with children. We will not share information that identifies you or your household outside our study team.

Mathematica takes your privacy very seriously. One risk of being in the study is that information about you might not stay private. We have taken steps to prevent this. We have strict rules to keep your data safe. We will remove names from any information we collect. No one from [GRANTEE AGENCY] will be allowed to see any of your answers from the phone survey.

Your participation is voluntary. There are no direct benefits for participating. You can decline to answer questions in the survey if you do not want to answer them. You can also stop being in the study at any time. If you do not want to be in the study, it will not affect any services your household receives from [GRANTEE AGENCY]. You can call [STUDY PHONE #] toll-free to stop being in the study.

If you agree to be in the study, please fill out and sign the form on the next page. Return the signed form to [GRANTEE AGENCY]. [GRANTEE AGENCY] will give Mathematica the information that is listed on the form. Mathematica will use this information to contact you to complete the phone surveys.

Please contact our team if you have questions about the study. You can call toll-free at [STUDY PHONE #] or email [STUDY EMAIL ADDRESS]. If you have questions about your rights as a study volunteer, you can call [IRB NAME] at [IRB PHONE #].

Sincerely,

Sarah Forrestal

EDECH Survey Director

CONSENT FORM

PRINT PARENT/GUARDIAN NAME:

MAILING ADDRESS:

PHYSICAL ADDRESS:

MAILING FOR UPS OR FEDEX SHIPMENTS:

HOME PHONE NUMBER:

WORK PHONE NUMBER:

CELL PHONE NUMBER:

EMAIL ADDRESS:

May we send text messages to your cell phone regarding benefits?: □ Yes □ No

May we send text messages to your cell phone regarding the phone survey?: □ Yes □ No

Preferred language for phone survey: □ English □ Spanish

Please print information for each child in your household. If a child is not in school, leave “grade” and “school” blank. If you need more space, continue on a new sheet of paper.

First Name	M.I.	Last Name	Gender	Race/Ethnicity	Birth Date	Grade	School

Week of the month you feel a food package would be most vital to your family:

□ 1st week □ 2nd week □ 3rd week □ 4th week

I have read the information about this study and understand that I am agreeing to participate in a study focused on helping families feed their children.

_____________________________________ 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.

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