Revised - Formative Research to Develop Educational Materials for Parents, Caregivers, and Child Care Providers of Children Ages 2-5 (SLT)

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Attachment K – Consent Form: CACFP Site

Background & Purpose: Your child care site and staff are invited to help improve and influence the development of nationally-available nutrition education materials by hosting small discussion groups and interviews on behalf of the United States Department of Agriculture (USDA) Food and Nutrition Service (FNS). The purpose of the discussions and interviews is to test updated health education materials for participants in the Child and Adult Care Food Program (CACFP).

Process: Small discussion groups will be conducted with parents and caregivers whose children are cared for at your center/home and 1-2 in-person interviews will be conducted with your director, providers/teachers, and staff involved in meal planning or preparation. Your site will provide one room that seats 6 to 8 people for the small group discussion and one room that seats 2-3 people for the interview. Both rooms should have doors, if possible. The room to be used for interviews should be free of children and adults not participating in the research for 1.5 hours. The room to be used for the small group discussions should be free of children and adults not participating in the research for 3 hours. The small group discussion and interview will be conducted on the same day. If your site agrees to host more than one small group discussion, the larger room will be needed for a second consecutive day. Interviews will be conducted with one person one at a time and scheduled as convenient for the site.

Possible Risks & Benefits: We do not anticipate any risks associated with being in this study.

Stipend: Your site will receive a $300 stipend to help cover the use of your facility during regular hours and after hours, assistance with recruiting of parents and caregivers to participate in the research, care for children of parents and caregivers participating in research, staff time for participation in interviews, and any other expenses that may be incurred.

Participants Rights: Participation in this study is voluntary. If you do not give your consent, we will not conduct the research at this location. You 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 you are otherwise entitled. Staff who participate in the interviews have the right to refuse to answer particular questions. Staff names, addresses, phone numbers, and e-mail addresses will only be used for contact about this research activity. They will not be given to anyone else for other purposes.

The research will be audio recorded for research purposes only. The name of your site and the names of any participating staff will never be used in any reports of our research findings. Facility information will be kept secure and only used for research purposes, except as otherwise required by law. We are required by law to report cases of child maltreatment.

Contact Information: If you have any questions, concerns or complaints about this research study, its procedures, risks and benefits, please contact Maria Sinopoli (973.377.0300, X16; [email protected]).

Your signature below indicates that you understand the conditions stated above and agree to make site resources and staff available for this research. You will be given a copy of this consent for your records.

Signature ___________________________________________ Date________________

Title: _______________________________________________

Site Name: _________________________________________________________

Location: __________________________________________________________