Individuals/Households - Households

APPENDIX I1. HOUSEHOLD SURVEY CONSENT FORM

OMB Number: 0584-0530

Expiration Date: XX/XX/XXXX

National School Meal Study (NSMS)

Household Survey Consent Form

PURPOSE: The United States Department of Food and Agriculture (USDA), Food and Nutrition Service (FNS) funds the National School Lunch and School Breakfast programs. These programs help schools in providing nutritious meals to children. The USDA is conducting a series of studies to gather up-to-date information about these programs, including: a) who they serve, b) how participants feel about the meal services they receive, and c) how eligibility for program participation is collected and reported. Through this study, the USDA wants to know more about how school meals are served and how schools determine household eligibility and report meal claims to the USDA. This Study includes a household survey conducted by a research organization, Westat.

HOW YOU WERE SELECTED: Your household was chosen randomly from a list of households that applied for benefits in the school meal programs.

INFORMATION TO BE COLLECTED: As the parent, or guardian, you will be asked about your child’s experience with the breakfast and lunch programs provided by your school, as well as household size and income information used to determine eligibility for meal benefits. We will give you a worksheet to prepare for the survey before we visit you. The interview will take place at your home, or anywhere you choose, at a time that you prefer.

RISKS AND PRIVACY: There is little risk to being part of this study. We use all data we collect only for the purposes we describe. Many steps are taken to keep your data private to the full extent allowed by law. Any reports we prepare will combine your answers with those from other people in the study to summarize what we found. Your or your child’s name or address will never be in the reports we prepare. Nothing you say is shared with the school your child attends or any agency that provides benefits to your household. Participating in the study may not help you individually, but your participation will help the USDA improve the National School Lunch and Breakfast program.

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 0584-0530. The time required to complete this information collection is estimated to average 5 minutes per response, including the time to review instructions, search existing data sources, gather and maintain the data needed, and complete and review the collection of information.

STUDY COSTS AND COMPENSATION: There is no cost to you to join this study. The interview takes about 45 minutes. As a thank you, you can receive a Visa gift card up to $50, depending on the tasks you complete. You will get $30 for completing the survey and you will get an extra $20 if you also provide the documents to verify your income. If you complete both parts you will receive a $50 Visa gift card.

VOLUNTARY PARTICIPATION: You do not have to take part in this study. It is your choice to be in this study, or not. You may skip any question you do not wish to answer and you can stop the interview at any time. Signing this consent form does not waive any of your legal rights. If you do not participate, you will not lose any benefits you may receive. Also, it will not impact any benefits the school district receives.

QUESTIONS: If you have questions now, you should talk to the interviewer. If you have questions about the study later, you may call Roline Milfort, the study project director, toll-free at 1-855-820-6138. If you have questions about your rights as a research participant, please call the Westat Human Subjects Protections office at 1-888-920-7631. Please leave a message with your full name, the name of this study (NSMS), and a phone number including the area code. Someone will return your call as soon as possible.

CONSENT SIGNATURES: I have been given the chance to ask questions about the study and all my questions have been answered to my satisfaction. I have read and understand this entire consent form, and agree to participate in this study.

Participant’s Name (Please Print): _________________________________________

Participant’s Signature: ___________________________ Date: ________________

Interviewer’s Signature: ___________________________ Date: ________________

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