Formative Research to Develop Multicultural Nutrition Education for Child Care (Individuals and Households - Children and Parents)

OMB Control # 0584-0524

Expiration Date: 9/30/2019

Attachment D.1 – Questionnaire for Participation in Focus Group Research (Print Version)

OMB 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 3 minutes 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.

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

1. How old are your child(ren)? Select all that apply.

( ) Younger than 2 years ( ) 5 years old

( ) 2 years old ( ) 6-8 years old

( ) 3 years old ( ) 9-12 years old

( ) 4 years old ( ) Older than 12

2. What is your Ethnicity?

( ) Hispanic or Latino ( ) Not Hispanic or Latino

3. What is your Race (select one or more)?

( ) American Indian or Alaska Native

( ) Asian

( ) Black or African American

( ) Native Hawaiian or Other Pacific Islander

( ) White

4. During the focus group, we will be discussing recipes from different cultures around the world. We want to make sure that these are culturally appropriate and relevant, so we’re looking for parents from different backgrounds to give their opinions. Are you from any of the following cultural or ancestral backgrounds? NOTE: You do not have to be from one of these backgrounds to participate.

( ) Asian Indian

( ) American Indian

( ) Native Alaskan

( ) Mexican

( ) Puerto Rican

( ) Chinese

( ) French

( ) Sub-Saharan African

5. What is your current age?

( ) Under 18 ( ) 35-44

( ) 18-25 ( ) 45-54

( ) 25-34 ( ) 55+

We will only contact you about the time and place of the focus group. What is the best way to reach you? (Select all that apply)

( ) Call

( ) Text

( ) Email

Please provide your contact information below. We will only contact you about this research.

Cell phone number: _____________________

Email address: ________________________

Privacy Statement:

Purpose: Information is collected primarily for use by Applied Curiosity Research on behalf of the Food and Nutrition Service of the US Department of Agriculture.

Authority: Federal statutes requiring studies of the food assistance programs: 7 U.S.C. 2011-27; 42 U.S.C. 1751-89; 7 U.S.C. 1431, 1431e, 612c, 612c note which is in the System of Record Notice in the Federal Registrar.

Routine Use: Information will only be used to contact you regarding the focus group interview. Please see System of Record Notice FNS-8, FNS Studies and Reports, published in the Federal Register on 4/25/1991 at 56 FR 19078

Disclosure: Furnishing the information on this form is voluntary, but failure to provide any contact information will result in withdrawal from participation in the focus group interview.