Parents/Guardians and Students - Individuals and Households

D10. PARENT ACTIVE CONSENT RESPONSE FORM - ENGLISH (GROUP 2)

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Note to Reviewers: The burden associated with the parent interview and parent-assisted dietary recall for elementary students is included in the burden disclosure statements on Appendices I3/I4 and I5. The burden associated with the parent interview for middle- and high-school students is included in the burden disclosure statement on Appendices I3/I4.

The School Nutrition and Meal Cost Study-II

Consent for Study Participation

The U.S. Department of Agriculture/Food and Nutrition Service (FNS) invites you to be a part of the School Nutrition and Meal Cost Study-II. This form explains what it means to be in the study. Please review, sign, and return this form in the enclosed stamped envelope. This is how you will indicate if you want yourself and your child to participate in the study.

What is the School Nutrition and Meal Cost Study-II?

Mathematica Policy Research, a research firm, is conducting this study for the U.S. Department of Agriculture (USDA) /Food and Nutrition Service (FNS). This study will help FNS improve federally sponsored school meal programs. It will also help FNS learn about students who take part in those programs. The study will examine how well schools are following nutrition guidelines for school meals. We will also look at whether school meals meet students’ nutritional needs. School districts, schools, and students were scientifically selected for the study.

What is expected of me and my child?

A study team from Mathematica Policy Research will visit your child’s school. We will meet with students, staff, and contact parents by email or phone. We will meet with students who eat school meals and those who do not eat them. We will ask students and their parents about school meals, students’ diets, and student characteristics. Survey questions will be age appropriate. Students and parents may skip any questions they do not wish to answer. Students’ height and weight will also be measured. These activities will take about 60 minutes of your child’s time, and (ELEMENTARY: 40; MIDDLE/HIGH: 25) minutes of your time.

Will my answers be kept private?

All information will be kept private under the Privacy Act to the extent allowed by law. The information you provide will be used for statistical purposes only. No information on individual students or families will be shared outside the study. No students or parents will be named or identified in any way.

Are there any risks or benefits?

There are no additional known risks to taking part in this study. Your responses will not affect services you or your student receive or may apply for in the future. Parents and students who choose to participate will receive a small payment to thank them for their help. Parents will receive a [ES: $25/MS/HS: $15] gift card after completing an interview. Students will receive a [ES: $5/MS/HS: $15] gift card.

Do I have to participate?

No. Taking part in the study is voluntary. We hope you take part in this important study, but it is your decision. Please read the enclosed materials to learn more about the study. If you do not want to participate, check off the “No” box on the back of this form and return it by [DATE]. If you do want to participate, check off the “Yes” box. Please sign and return the form either way, so that we know your decision. You or your child may change your mind at any time about participating.

If you have any questions about the study, please contact [SCHOOL LIAISON] at xxx-xxxx or call [MATHEMATICA CONTACT NAME] at 1-866-xxx-xxxx.

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. 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-xxxx). Do not return the completed form to this address.

If you have any questions about your rights as a research participant, please contact [FILL IRB CONTACT INFORMATION].

School Nutrition and Meal Cost Study-II

I have read the information about this study and understand that I am being asked to participate and to allow my child to participate in the School Nutrition and Meal Cost Study-II.

	YES, my child CAN participate in the School Nutrition and Meal Cost Study-II.
		| | |/| | |/| | | | |
Parent/Guardian Signature		MM/DD/YYYY
What is your email address?
What is the best phone number to reach you? (| | | |)| | | | - | | | | |
(Check one) □ Cell phone □ Landline
Can we send you text messages for the study?
(Check one) □ Yes □ No

OR

	NO, my child CANNOT participate in the School Nutrition and Meal Cost Study-II.
		| | |/| | |/| | | | |
Parent/Guardian Signature		MM/DD/YYYY

STUDENT’s School: [PRE-FILLED]

NAME OF STUDENT: [PRE-FILLED]

PLEASE RETURN THIS FORM IN THE ENCLOSED STAMPED ENVELOPE BY [DAY, DATE].