Individuals/Households

APPENDIX C19. NAMES SURVEY CONSENT FORM

National Assessment of Meal Eligibility and Services (NAMES) Study

Survey Consent Form

OMB Number: 0584-XXXX

Expiration Date: XX/XX/XXXX

PURPOSE: The Food and Nutrition Service (FNS) of the U.S. Department of Agriculture (USDA) is studying the Child and Adult Care Food Program, or CACFP, in child care centers. Westat and its partners, Kokopelli Associates and Windwalker Corporation, have a contract to do this national study to learn more about how the CACFP functions and if its benefits are used as planned. Joining this study may not help you personally but it may help USDA to improve the program.

HOW YOU WERE SELECTED: The child care center your child attends is in the CACFP. The study team used a scientific method to randomly pick your household from a list of enrolled children at the child care center.

INFORMATION TO BE COLLECTED: As the parent, or guardian, you will be asked about experiences with the child care center food program by an interviewer who records the answers. The survey also asks about your household size and family income. Once a visit is scheduled a packet will be sent to you to help you prepare for the interview. The interview will take place at your home, or anywhere you choose, at a time that you prefer.

RISKS AND PRIVACY: There is little risk to being part of this study. We use all data we collect only for the purposes we describe. Many steps are taken to keep your data private to the full extent allowed by law. Any reports we prepare will combine your answers with those from other people in the study to summarize what we found. Your or your child’s name or address will never be in the reports we prepare. Nothing you say is shared with the child care center your child attends or any agency that provides benefits to your household.

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 5 minutes per response, including the time to review instructions, search existing data sources, gather and maintain the data needed, and complete and review the collection of information.

STUDY COSTS AND COMPENSATION: There is no cost to you to join this study. The interview takes about 45 minutes. As a thank you, you can receive up to $50, depending on the tasks you complete. You will get $30 for completing the survey and you will get an extra $20 if you also provide the documents to verify your income. If you complete both parts you will receive a $50 gift card.

VOLUNTARY PARTICIPATION: You do not have to take part in this study. It is your choice to be in this study, or not. You may skip any question you do not wish to answer and you can stop the interview at any time. Signing this consent form does not waive any of your legal rights.

QUESTIONS: If you have questions now, you should talk to the interviewer. If you have questions about the study later, you may call Roline Milfort, the study project director, toll-free at 1-855-272-0058. If you have questions about your rights as a research participant, please call the Westat Human Subjects Protections office at 1-888-920-7631. Please leave a message with your full name, the name of this study (NAMES), and a phone number including the area code. Someone will return your call as soon as possible.

I have been given the chance to ask questions about the study and all my questions have been answered to my satisfaction. I have read and understand this entire consent form, and agree to participate in this study.

Child’s Name (Please Print): _____________________________________________

Parent’s Name (Please Print): ____________________________________________

Parent’s Signature: ______________________________ Date: ________________

Interviewer’s Signature: ___________________________ Date: ________________

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