Individuals/Households - Parents & Children

C.9a. Parent Consent and Permission Form (English)

OMB Control No. 0584-xxxx
OMB Approval Expirations Date: xx/xx/xxxx

Abt IRB Approval No. 0804

Parent Consent and Permission Form

The U.S. Department of Agriculture invites you and your child to be a part of the Study of Nutrition and Activity in Child Care Settings (SNACS). This form explains what it means to be in the study.

What is the SNACS?

The child care center, family day care home, or program where your child receives child care is part of a national study. The study is being conducted by the U.S. Department of Agriculture. The study will look at the food and activities provided to infants and children in a sample of child care providers. There will be more than 1,500 child care providers in the study in over 20 states. In addition, the study will include about 3,000 infants and children and more than 4,000 parents of infants and children getting care in the child care centers and homes in this study. As part of the study, child care providers at the place where your child receives child care will be asked about meals they serve to infants and children, play activities they provide for children, and costs of meals served. Study staff will also observe your child while in child care to look at the kind of food he/she is given at mealtimes and what kind of activities they are involved in. In addition, parents will also be asked to take part in study activities. The study is being conducted by Abt Associates and Abt SRBI.

What is expected of me and my child?

Parents who agree for themselves and their child to be part of the study will be asked to sign and return this Parent Consent and Permission Form.

Parents who agree to be in the study will be asked to take part in a short telephone interview with a member of the study team. During this interview, parents will be asked about their child such as your child’s child care arrangements, your child’s activities, the food your child brings to child care from home, and other services that your family receives. This parent telephone interview will take about 15 minutes.

{If applicable: Parents will also be asked to write down all the foods that their child eats while at home over two or three days on a form called the Child Food Diary. Parents will receive between $20 and $30 for each day they complete this form. Parents will receive $20 for completing the form on a day when their child is in childcare. Parents will receive $30 for completing the form on a day when their child is not in childcare. Each of these forms will take about 40 minutes to complete. Parents selected for this part of the study will be told more about the Child Food Diary by a member of the study team at their child’s child care provider.}

{If applicable: Parents will allow their child’s weight and height to be measured by carefully trained members of the study team.}

{If applicable: Members of the study team will also be observing meals and/or activities during the time that your child is in child care.}

Will information collected about me and my family be kept private?

All information collected about children and families in the study will be kept private to the fullest extent allowed by law. No information that identifies children or family members will be shared outside the study. The names of children and families members will never appear in any report or with any study findings. Any forms or other papers that include your name will be kept in a locked storage area. Any computer files with your name will be locked and protected. Any researchers using information to study the program must follow all data security rules.

Are there any risks or benefits to being in the study?

There is a very small risk of loss of confidentiality but the study team has taken many steps to reduce this risk. Being in the study will not affect your child care or any other services that you or your family receives or may apply for in the future.

Parents will receive $10 in the form of prepaid Visa cards for their time signing and returning this Parent Consent and Permission Form.

[If applicable: Parents who are selected and agree to provide information about food his/her child eats outside of child care will be provided between $20 and $30 in the form of prepaid Visa cards for each day they provide this information on the study form.}

Is the study voluntary?

Yes, taking part in the study is voluntary. You or your child may change your mind at any time about being in the study.

Questions about the Study?

If you have any questions, please call our toll-free study hotline at 844-808-4777. For questions or concerns about your rights as a research participant, call Katie Speanburg at the Abt Associates Institutional Review Board at toll-free 877-520-6835.

I have read the information about this study and understand that I am being asked to participate and to allow my child to participate in the SNACS.

I will mark the YES box, sign, and date this form if I agree to participate and to allow my child to participate in this study. I will mark the NO box, sign, and date this form if I do not agree to participate and do not allow my child to participate in this study.

YES, I agree to be in the study and agree that my child can participate in this study. I will allow the study team to contact me using my contact information below.

Child Name: Child’s Date of Birth: ____/____/______

MM / DD / YYYY

Parent/Guardian Name:

Address (Street, City, State):

Telephone Number (Home): Best time to call:

Telephone Number (Cell): Best time to call:

E-mail address:

Days of the week your child typically attends child care at this facility during the school year (check all that apply):

□ Mondays □ Tuesdays □ Wednesdays □ Thursdays □ Fridays

Days of the week your child typically attends child care at this facility during the summer (check all that apply):

□ Mondays □ Tuesdays □ Wednesdays □ Thursdays □ Fridays

NO, I do not agree to be in the study and do not agree that my child can participate in this study.

__________________________ ____/____/______

Parent/ Guardian Signature MM / DD / YYYY