Appendix D12. Student Assent Form - English (Group 2)

D12. STUDENT ASSENT FORM – ENGLISH (GROUP 2)

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School Nutrition and Meal Cost Study-II

Student Assent

Who is conducting the study? The study is for the U.S. Department of Agriculture/Food and Nutrition Service. This is the part of the federal government that is responsible for school meal programs. Mathematica Policy Research is a research company that was hired to collect all the information for the study.

What do I have to do? A study interviewer visiting your school will ask you questions about yourself, school meals, and what you ate. The interviewer will also measure your height and weight. At the end, the interviewer will give you a gift card for helping with the study.

Do I have to participate in the study? No. You can decide if you want to be in the study or not.

Will anyone know I am in the study? No. Your name will not be part of the study, and your answers will be kept private.

Will my answers be kept private? Yes. All information gathered for the study is private under the Privacy Act to the extent allowed by law. The person who will interview you is not allowed to share your personal information with anyone except other people working on this study. Your name will not be part of the study.

What if I do not eat school meals? Even if you do not eat the school breakfast or lunch, we still want you to be in the study. It is important for the study to learn about both students who eat school meals and students who do not.

Who can I talk to about the study? If you or your parents have any questions about the study, you can call Mathematica toll free at 1-888-xxx-xxxx. If you or your parents have any questions about your rights as a research participant, please contact [FILL IRB CONTACT INFORMATION].

Your parent(s)/guardian(s) received a letter and brochure that explains what we are asking you to do. They can contact Mathematica at any time if they do not want to give permission for you to participate or if they have any questions about it.

It is your decision to participate in the study. Anything you say to the study interviewer will only be shared with the people working on this study. You can tell the study interviewer at any time if you decide not to participate. You are always free to change your mind.

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 3 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.

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