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

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Attachment G – Consent Form: Parent/Caregiver Triads (English)

Background & Purpose: You are invited to participate in a small group discussion on behalf of the United States Department of Agriculture (USDA) Food and Nutrition Service (FNS) to test updated health education materials for participants and providers/operators of the Child and Adult Care Food Program (CACFP).

Process: As part of the research, you will participate in a 90 minute discussion with a representative of Diversity Marketing and Communications/ICF and other parents and caregivers on [date] at [location]. Results from this discussion will be used to improve and influence the development of nationally-available nutrition education materials.

Possible Risks & Benefits: We do not anticipate any risks associated with participating in these discussions.

Compensation: You will receive $50 in the form of a Visa or MasterCard gift card to offset any costs that you may incur by participating in this research.

Participants Rights: Participation in this discussion is voluntary. If you do not give your consent, you will not participate in the discussion. You have the right to change your mind and withdraw your consent or stop participating at any time without any penalty or loss of the benefits to which you are otherwise entitled. You have the right to not respond to any questions that you do not want to answer. Your name, address, phone number, and e-mail address will only be used to contact you about this research activity. They will not be given to anyone else for other purposes. The discussion may be audio recorded for research purposes only. Your name will never be used in any notes or reports of our research findings. Your 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 participate in this discussion. You will be given a copy of this consent for your records.

Signature ___________________________________________ Date________________