Team Nutrition Educational Technology Environmental Scan

OMB Control # 0584-0524

Expiration Date: xx/xx/20xx

Appendix A – Teacher Email, Teacher Informed Consent Form for Focus Group Participation, and Questionnaire for Participation in Focus Groups (Consent Package for School Focus Groups)

OMB BURDEN STATEMENT: This information is being collected to assist the Food and Nutrition Service (FNS) in providing the public with information concerning its child nutrition programs. This voluntary information will be used to develop nutrition education resources and interventions for population groups served by FNS. Under the Privacy Act of 1974, any personally identifying information obtained will be kept private to the extent provided by law. According to the Paperwork Reduction Act of 1995, no persons are 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 to complete this information collection is estimated as part of the 12 minutes for the screener, including the time for reviewing instructions and completing the information. Send comments regarding this burden estimate or any other aspect of this collection of information, including suggestions for reducing this burden, to: U.S. Department of Agriculture, Food and Nutrition Service, Office of Policy Support, 3101 Park Center Drive, Room 1014, Alexandria, VA 22302 ATTN: PRA (0584-0524). Do not return the completed form to this address.

[DATE], 2016

Dear Educator,

My name is [Researcher’s Name] and I work for the Michael Cohen Group, a research firm that specializes in children, education and media.

We are currently looking for teachers at your school to share how they use technology to teach and communicate with their students. The United States Department of Agriculture (USDA) is sponsoring this effort in order to help development of new technologies, programs, and materials that will eventually be available to all teachers at no cost.

To this end, we are looking for teachers to participate in a 45-minutes focus group at your school, either before school, during lunch, or after school, depending on your availability.

A hot meal will be provided to all teachers that volunteer to participate.

If you would like to participate in the focus group, please click [insert link to consent form and survey] to fill out a brief survey and consent form, or contact [insert designated coordinator].

Thank you for your consideration and we look forward to working with you.

Sincerely,

[Researcher]

OMB BURDEN STATEMENT: This information is being collected to assist the Food and Nutrition Service (FNS) in providing the public with information concerning its child nutrition programs. This voluntary information will be used to develop nutrition education resources and interventions for population groups served by FNS. Under the Privacy Act of 1974, any personally identifying information obtained will be kept private to the extent provided by law. According to the Paperwork Reduction Act of 1995, no persons are 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 to complete this information collection is estimated as part of the 12 minutes for the screener, including the time for reviewing instructions and completing the information. Send comments regarding this burden estimate or any other aspect of this collection of information, including suggestions for reducing this burden, to: U.S. Department of Agriculture, Food and Nutrition Service, Office of Policy Support, 3101 Park Center Drive, Room 1014, Alexandria, VA 22302 ATTN: PRA (0584-0524). Do not return the completed form to this address.

Teacher Informed Consent Form for Focus Group Participation

STUDY TITLE: Educational Technology Environmental Scan

PROTOCOL NUMBER: XXXX

PRINCIPAL INVESTIGATOR:	Marha Hadley, Ph.D.
TELEPHONE:	212-431-2252
ADDRESS:	Michael Cohen Group LLC 375 West Broadway, Suite 502 New York, NY 10012

BACKGROUND AND PURPOSE:

You are invited to participate in a research study conducted by Michael Cohen Group (MCG) as part of a United States Department of Agriculture (USDA) sponsored effort to understand the landscape of technology in K-12 schools. MCG is an education research firm that specializes in children, education, and media.

We are interested in learning about how technology is currently used by K-12 teachers to help students learn and to communicate with children and their families to help develop new technologies, programs, and materials that are convenient and useful for teachers. If you participate, you will be asked about your attitudes about and experiences with educational technology.

PROCEDURES:

You will be asked to participate in a focus group interview in which you will discuss your experiences with and attitudes about educational technology, as well as the challenges, benefits, barriers, and best practices associated with using technology to help students learn and communicate with students and their families. The interview will be done in a group setting with other teachers from your school. The interview will last about 45 minutes and will take place at your school at a time that is convenient for you. About 155 teachers will participate in total across the country, about 4 per group. The interview will be audio-recorded for research purposes only.

POSSIBLE RISKS AND BENEFITS:

We do not anticipate any risks associated with being in this study. We do not promise that you will receive any benefits from this study. However, we do anticipate that most people will enjoy participating in the research process and the research will lead to the development of free teacher resources that will be developed by the USDA.

COMPENSATION:

You will not receive monetary compensation for your participation, but you will be provided with a hot meal at the time of the focus group.

PARTICIPANTS’ RIGHTS:

Participation in this study is voluntary. We will not work with you unless you give your consent. You have the right to change your mind and withdraw your consent or discontinue participation at any time without any penalty or loss of the benefits to which you are otherwise entitled. You have the right to refuse to answer particular questions.

Your name, addresses, and phone numbers will only be used to contact you about this research activity. They will not be given to anyone else for other purposes. The research will be audio-recorded for research purposes only. Your name will never be used in any reports of our research findings. Your information will be kept secure and only used for research purposes, except as otherwise required by law. All data will be identified only by an ID number, not by any name.

CONTACT INFORMATION:

Questions, Concerns, or Complaints: If you have any questions, concerns or complaints about this research study, its procedures, risks and benefits, please contact the Principal Investigator, at the telephone number listed on the first page of this form.

If you have any questions or complaints about your rights as a research subject, contact:

• Mail:

Study Subject Adviser

Chesapeake Research Review, Inc.

7063 Columbia Gateway Drive, Suite 110

Columbia, MD 21046

• Call collect: 410-884-2900

• Email: [email protected]

Teacher Informed Consent Form

Please complete the sections below. A copy of this form will be emailed to you for your records.

I, _____________________________________, agree to participate in this research

[your name]

project with the Michael Cohen Group. I understand that I may stop participation at any time.

_______________________________________________ _________________

Signature Date

____________________________________________

Phone (for research purposes only)

____________________________________________

Email Address (for research purposes only)

OMB BURDEN STATEMENT:  This information is being collected to assist the Food and Nutrition Service (FNS) in providing the public with information concerning its child nutrition programs. This voluntary information will be used to develop nutrition education resources and interventions for population groups served by FNS. Under the Privacy Act of 1974, any personally identifying information obtained will be kept private to the extent provided by law. According to the Paperwork Reduction Act of 1995, no persons are 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 to complete this information collection is estimated as part of the 12 minutes for the screener, including the time for reviewing instructions and completing the information. Send comments regarding this burden estimate or any other aspect of this collection of information, including suggestions for reducing this burden, to: U.S. Department of Agriculture, Food and Nutrition Service, Office of Policy Support, 3101 Park Center Drive, Room 1014, Alexandria, VA 22302 ATTN: PRA (0584-0524). Do not return the completed form to this address.

Questionnaire for Participation in Focus Groups

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

1. What grade(s) do you teach (please check at that apply)?

( ) Kindergarten ( ) 7^th Grade

( ) First Grade ( ) 8^th Grade

( ) 2nd Grade ( ) 9^th Grade

( ) 3^rd Grade ( ) 10^th Grade

( ) 4^th Grade ( ) 11^th Grade

( ) 5^th Grade ( ) 12^th Grade

( ) 6^th Grade

2. What subject(s) do you teach (please check at that apply)?

( ) English Language Arts ( ) Physical Education

( ) Math ( ) Health

( ) Science ( ) Professional Studies

( ) Nutrition ( ) Technology

( ) History ( ) Arts or Music

( ) Social Studies ( ) Library/Library Science

( ) Foreign Language Studies ( ) Other__________

3. How many years have you been teaching?

( ) First year

( ) 2-5 years

( ) 6-10 years

( ) 11-15 years

( ) Over 15 Years

4. Ethnicity

( ) Hispanic or Latino

( ) Not Hispanic or Latino

5. Race (select one or more)

( ) American Indian or Alaskan Native

( ) Asian

( ) Black or African American

( ) Native Hawaiian or Other Pacific Islander

( ) White

6. What is your current age?

( ) Under 25

( ) 25-34

( ) 35-44

( ) 45-54

( ) 55+

7. What is your gender?

( ) Female

( ) Male