Parents (Individuals/Households)

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

Appendix B-4-2. Consent Letter for Parent

CACFP Feasibility Study

Parental Consent for Participation in Data Collection Using CARS

OMB Number: 0584-XXXX

Expiration Date: XX/XX/XXXX

Purpose

The U.S. Department of Agriculture, the federal agency that reimburses meals your family day care provider serves to your child under the Child and Adult Care Food Program, 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

If you choose to participate, we ask that you report the times you drop off and pick up your child/children at day care for 1 month, using a special text message system. Participation in the study is voluntary; you can stop your reporting at any time. If you have any questions, contact the project toll-free number,
1-800-912-9384.

Risks and Benefits

There is minimal to no risk to you or your child for participating in this study. There will be no direct benefit to you or to your day care provider for participating in this study. The information you report will not affect the meals served or your provider’s reimbursement for the meals.

Compensation

If you agree to participate, you will receive $25 Visa gift card in compensation for any expenses you incur in using your cell phone. You will receive the $25 Visa gift card even if you choose not 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 6 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, your child/children, or the day care homes. If you have more than one child enrolled in the day care home, your child’s first name will be reported so we know which child’s attendance you are reporting. 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

If you agree to participate, you have the right to change your mind and terminate the study at any time.

Voluntary Consent

[If administered by phone, add:]

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

By agreeing to 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.]

We will provide you with a copy of this consent form upon your request. Please return the consent form in the envelope we provided or call 1-800-912-9384 to give your consent verbally.

B-4-2.1