Request Approval to Perform Research for Team Nutrition Posters-Phase 2

Attachment E

OMB Control # 0584-0524

Expiration Date: 06/30/2016

OMB BURDEN STATEMENT: According to the Paperwork Reduction Act of 1995, no persons are 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 0584-0524. The time required to complete this information collection is estimated to average 5 minutes per response, including time to review instructions, search existing data resources, gather the data needed, and complete and review the information collection.

USDA Food and Nutrition Service

Agreement on Security of Comments for Parents

I, __________________________(print name), and my child, _____________________________ (print name) agree to keep all information shown and discussed during the USDA focus group in which my child is participating in the strictest confidence.

I agree not to discuss, publish, or otherwise divulge any information I am exposed to, in whole or in part, in any manner or form through my child’s participation.

Signed:___________________________ Dated: ____________________

Your child’s comments will be kept secure and only used for research purposes except as otherwise required by law. His or her name, as well as your name, will not be divulged in any reports of this focus group.

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FNS Team Nutrition Poster Testing Formative Research Phase 2

Attachment E: Agreement on Security of Comments - Parents