Middle School Digital Nutrition I/H

OMB Control # 0584-0524

Expiration Date: 6/30/2016

Attachment B – Parent/Caregiver Letter, Informed Parent/Caregiver Consent Form for Student Participation, Parent Questionnaire (Consent Package for Parent/Caregivers)

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 to complete this information collection is estimated as part of the 10 minutes for the screener, including the time for reviewing instructions and completing the information.

[DATE], 2016

Dear Parent/Caregiver,

My name is [Researcher’s Name] and I work for the Michael Cohen Group, a research firm that specializes in children, education, and media.

We are currently working with your child’s school to develop materials and lessons for middle school students about nutrition. The United States Department of Agriculture (USDA) Food and Nutrition Service (FNS) is sponsoring this effort. We are interested in getting feedback from students about these materials.

Specifically, the lessons will raise awareness of the importance of healthy food choices and physical activity among middle school children. The curriculum will include reading passages, interactive computer-based applications, and videos. It is important for us to get student feedback about these materials so the final products are relevant, meaningful, and fun. To this end, we will be conducting focus groups with teachers and students at your child’s school and would like to include your child in an upcoming focus group.

Included with this letter you will find a consent form with additional information and a brief survey. If your child wishes to participate in the student focus groups, please complete these forms and return to your child’s teacher, [insert teacher’s name].

Thank you for your consideration and we hope you will give permission for your child to participate.

Best,

[Researcher’s Name]

Parent/Caregiver Informed Consent for Student Participation Form

STUDY TITLE: USDA FNS Digital Nutrition Education Materials for Middle School Students and Teachers

PROTOCOL NUMBER: XXX

PRINCIPAL INVESTIGATOR:	Gerad O’Shea
TELEPHONE:	212-431-2252
ADDRESS:	Michael Cohen Group 375 West Broadway, Suite 502 New York, NY 10012

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 to complete this information collection is estimated as part of the 10 minutes for the screener, including the time for reviewing instructions and completing the information.

BACKGROUND AND PURPOSE:

Your child is invited to participate in a research study conducted by Michael Cohen Group as part of a United States Department of Agriculture (USDA) Food and Nutrition Service (FNS) sponsored effort. USDA/FNS is developing a free curriculum that will raise awareness of the importance of healthy food choices and physical activity among middle-school children. Michael Cohen Group is an international research firm that specializes in children, education and media that is partnering with USDA/FNS on this effort.

We are working to help develop nutrition lessons that include informational texts, interactive applications and videos that promote healthy food choices and physical activity. If your child chooses to participate, s/he will discuss the types of projects and activities they like, and will be asked to brainstorm engaging educational activities and respond to a select list of draft concepts.

PROCEDURES:

As part of this research project, your child will be asked to participate in a focus group interview about nutrition education materials. The interview will be done in a small group setting with other students in your child’s school. The interview will last about 45 minutes. About 72 middle school students will participate in total, 6 per group. Interviews will be audio-recorded for internal research purposes only.

POSSIBLE RISKS AND BENEFITS:

We do not anticipate any risks associated with being in this study. While we do not promise that your child will receive any benefits from this study, we anticipate that most children will enjoy participating in the research process.

STIPEND:

At the end of the study, your child will be thanked for his/her participation.

PARTICIPANTS’ RIGHTS:

Participation in this study is voluntary. We will not work with your child unless you give your consent. If you give permission for your child to be in the study, but your child does not want to participate, then your child will not be in the study. Your child will be reminded that participation is voluntary by our researchers before the start of the activities. You and your child both have the right to change your mind and withdraw your consent or discontinue participation at any time without any penalty or loss of the benefits to which s/he is otherwise entitled.

Your child has the right to refuse to answer particular questions. Their comments will be kept secure and only used for research purposes, except as otherwise required by law. Neither your name or your child’s name will be divulged in any reports of this research.

The research will not be used in any advertising. Your child will not be identified in any reports. All data will be identified only by an ID number, not by any child’s name. The research may be audiotaped for research purposes only. Your child’s name will never be used in any documentation of our research findings. Your child's voice, or image will not appear in public as a result of participating in this research.

CONTACT INFORMATION:

Questions, Concerns, or Complaints: If you have any questions, concerns or complaints about this research study, its procedures, risks and benefits, please contact the Principal Investigator, at the telephone number listed on the first page of this form.

If you have any questions or complaints about your rights as a research subject, contact:

• Mail:

Study Subject Adviser

Chesapeake Research Review, Inc.

7063 Columbia Gateway Drive, Suite 110

Columbia, MD 21046

• Call collect: 410-884-2900

• Email: [email protected]

Please discuss this study with your child. Please complete the section(s) below if you agree to allow your child to participate, and return to your child’s teacher.

My child, _____________________________________, has my permission to

[First and Last Name of Child]

participate in this research project with the Michael Cohen Group. I have also discussed the study with my child and s/he has indicated that s/he would like to participate in the study. My child and I both understand that either of us may stop my child’s participation at any time.

_______________________________________________ _________________

Signature(s) of Parent(s) or Legal Guardian Date

_______________________________________________

Print First and Last name of Parent or Legal Guardian

Parents/Caregivers Survey for Participation in Focus Groups

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 to complete this information collection is estimated as part of the 10 minutes for the screener, including the time for reviewing instructions and completing the information.

Please choose the option that best answers each question for you.

1. Are you the parent or guardian of any children in middle school who live at home with you?

( ) yes

( ) no

2. What age(s) are your child(ren) that are currently in middle school? (check all that apply)

( ) 4^th Grade ( ) 7^th Grade

( ) 5^th Grade ( ) 8^th Grade

( ) 6^th Grade ( ) 9^th Grade

3. Your Gender

( ) Female ( ) Male

4. What is your current age?

( ) Under 25

( ) 25-34

( ) 35-44

( ) 45-54

( ) 55+

5. Your Ethnicity

( ) Hispanic or Latino

( ) Not Hispanic or Latino

6. Your Race (select one or more)

( ) American Indian or Alaskan Native

( ) Asian

( ) Black or African American

( ) Native Hawaiian or Other Pacific Islander

( ) White

7. What is your country of origin? _______________________

8. Does anyone in your household work in any of the following industries?

( ) Nutrition/Food Service ( ) Fitness

( ) Food manufacturing ( ) School Food Service

( ) Food/Nutrition Assistance Programs

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