Nutrition Education and Promotion Toolkit for Teens - Focus Group Testing

Attachment B OMB No. 0584-0524

Exp. Date 06/30/2016

Attachment B

Parent/Guardian Consent Form for Student Participation

Site: ______________________________
Date: _____________________________

PARENT/GUARDIAN CONSENT FORM FOR

HIGH SCHOOL STUDENT PARTICIPATION IN A DISCUSSION GROUP

WHY WE ARE CONDUCTING RESEARCH

KRC Research, an independent opinion research company that specializes in conducting third party research for organizations of all kinds, is holding small discussion groups across the United States with 10^th, 11^th, and 12^th graders. As they’re sometimes called, these focus groups are to hear teen opinions about healthy eating, and physical exercise. KRC is a leading independent research company. You can learn more about KRC at krcresearch.com.

KRC is conducting these discussion groups with students for the U.S. Department of Agriculture’s (USDA), Food and Nutrition Service (FNS). Hearing from students directly about their ideas and interests regarding nutrition and exercise will help FNS to develop interesting and engaging lesson plans for high school students.

Each discussion group will include 8 to 10 students and will last two hours. The groups in your area will be held at a professional research facility at [location] on [date, time].

If your teenager qualifies for and participates in one of our discussion groups, she or he will receive a cash payment of $75 for his or her participation.

HOW IT WORKS

As part of this research project, KRC’s team of researchers will host a two-hour focus group at a professional research facility where your teenager will be in a group with other students near her or his age.

Students should arrive at the research facility 30 minutes before the start of the group to check in with the host and KRC’s research assistant. If they have a smartphone or tablet, they should bring it with them. During this check-in time, students will participate in a 15 minute pre-group exercise. The pre-group exercise will involve briefly looking at a website on food and nutrition from a smartphone or tablet. KRC will also have tablets on hand for students to use.

The discussion will start on time, and it will be led by an adult researcher who is a professional group moderator, and a research assistant. The moderator will explain how the discussion group works, and students will introduce themselves to the group. The moderator will lead the conversation by asking the group questions about food, nutrition, and exercise and will show the group some ideas to get their feedback. The discussion is not a test, and there are no right or wrong answers. We are simply interested in teen views on healthy living and how to make learning about this topic fun and engaging. We welcome all opinions and ideas, and every child will be treated with respect.

This focus group is voluntary, meaning that with your permission, your son or daughter has the choice to participate or not.

If he or she chooses to participate, he or she does not have to answer any questions he or she does not want to answer, and he or she may leave the group at any time.

Everything your child says is private. Your child will not be identified in any information shared with FNS. All discussion groups will be video and audio recorded so we have accurate records of the discussions to use when we write the report. These recordings are only used by our research team for reporting. They will not be shared publicly and all information will be destroyed after the project is completed.

Finally, in accordance with Privacy Act provisions, System of Record Notice USDA/FNS-8, FNS Studies and Reports, published in the Federal Register on 4/25/1991 at 56 FR 19078, covers personal information collected under this study and identifies safeguards for the information collected.

Parent/Guardian Permission

Are you willing to have your child participate? If so, please complete and sign the following:

I agree to allow my son or daughter, __________________________, to take part in a small group discussion on food, nutrition, and physical exercise led by KRC Research for FNS.

I have read this Parent/Guardian Consent Form and I understand how the group will work and the purpose.

Parent/Guardian Signature: ____________________________________________________

Parent/Guardian Name (Please print): ____________________________________________

Date: _______________

If you have any questions about the research, please call [INSERT CONTACT AT FOCUS GROUP FACILITY].

Office of Management and Budget BURDEN STATEMENT:  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 0584-0524. The time required to complete this information collection is estimated to average 5 minutes (.08 hours) 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.