Sponsors and Providers

OMB Control Number 0584-NEW: Child and Adult Care Food Program (CACFP) Family Day Care Homes Meal Claims Feasibility Study

Appendix B-4-1. Consent Letter for Provider

CACFP Feasibility Study

Family Day Care Provider Consent for Participation in Data Collection

OMB Number: 0584-XXXX

Expiration Date: XX/XX/XXXX

Purpose

The U.S. Department of Agriculture, the federal agency that provides the funds for the reimbursement of meals you serve in CACFP, is conducting a study on meal claiming in the CACFP to strengthen the program further. The USDA has hired a research company, Manhattan Strategy Group, to find out whether day care providers are asking for and receiving the correct amount of reimbursement for meals they serve.

Description of Participation

Participation in this study is voluntary but strongly encouraged under the terms of your role as a CACFP provider and the authorization for this study by the USDA. You are asked to use a specially developed app on your smartphone, or on the Web, each day for one month to report the times you serve meals to each child in attendance, as well as the type of meal you serve. You will do this in addition to your current recordkeeping. If you have any questions, contact the project director at the project help desk’s toll-free number, 1-800-912-9384.

Risks and Benefits

There will be minimal to no risk to you or the children in your care for participating in this study. There will be no direct benefit to you for participating in this study. The information you report will not affect your reimbursement for meals you serve.

Compensation

You will receive $60 Visa gift card in compensation for any expenses you may incur in reporting data for the study, such as use of your cell phone. You will receive the $60 Visa gift card even if you are not able to complete the study reporting.

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 for reviewing instructions, searching existing data sources, gathering and maintaining the data needed, and completing and reviewing the collection of information.

Privacy

Information on attendance will be reported only in the aggregate, for all participants as a group. We will not report full names, telephone numbers, or location information for you, the children in your care, or the day care homes. We will report the first names of children in your care with meal serving times. The only exceptions to this are situations in which information about physical harm to you or others is disclosed; we are required by law to report any information we may obtain during the study about imminent danger to you or others.

Rights Regarding Decision to Participate

Your participation is voluntary; however, if unforeseen circumstances arise during the course of the study month that affect your participation, please contact us at 1-800-912-9384.

Consent

[If administered by phone add:]

In your own words, what are the risks and benefits, if any, of participating in this study?

By signing this consent form, I certify that I have read it and understand its content, and that I have obtained answers to any questions I may have had about it.

Printed Name: _______________________________________

Date:­­­­­­­­­­­­­­­­­ ___________________________

Signature: _____________________________________________________________________

[Signature of MSG staff if consent received via phone.]

Please return consent form in the envelope provided, scan it and email to [email protected], or call 1-800-912-9384 to give your consent verbally.

B-4-1.1