Informed Consent and Contact Information

9. Study Consent

Consent Form

Congratulations! You are eligible to take part in the Feeding My Baby and Me Study.

Please read and submit this form if you decide to take part in this important study.

Study Sponsor: The Feeding My Baby and Me Study is sponsored by the Centers for Disease Control and Prevention (CDC) and carried out by Westat [LINK TO WESTAT.COM].

Study Purpose: CDC is doing the study to learn more about the choices mothers make in feeding their babies in the first 2 years of life. The information you provide may help improve the health of our nation’s children.

What Would I Do As A Study Participant?

• Complete Web Surveys over a two-year period about your health, your baby’s health, your experiences as a parent, and feeding and caring for your baby.

• We will ask you to complete the first survey before your baby is born. After your baby is born, we will ask you to complete surveys, within 2 weeks of each request, when your child is 1, 2, 3, 4, 5, 6, 8, 10, 12, 15, 18, 21, and 24 months.

• We will also ask you to complete at least two, and up to four, web food surveys about what you eat. The first while you are pregnant and the second when your baby is 3 months old. These will need to be completed the day you receive the survey invitation.

As a token of our appreciation, we will give you $30 for each web survey and $50 for each web food survey. If you complete all surveys, you will receive up to $620.

• Provide Contact Information. We will ask you to provide your contact information so we can reach you for the surveys. We may also use it to invite you to participate in a follow-up study when your child is older. We will not use your contact information for any other purpose.

Who Continues to be Eligible? To stay eligible after your child is born (1) you must give birth to your baby in your 37^th week of pregnancy or later, (2) your baby cannot spend 3 or more days in the Neonatal Intensive care Unit (NICU), and (3) you cannot be too sick to feed your baby for more than 6 days.

What Are the Risks? We expect that your time in the study will be interesting and pleasant, and will not cause you discomfort. There is, however, a small risk to privacy since you are entrusting us with personal information. However, we will take many precautions to protect your privacy.

• We will not use your name and your child’s name in any research reports.

• We will assign a study ID to your information, and only a small number of study staff will have access to the connection between study IDs and actual names.

• All study information will be stored on secure computer servers at Westat.

• We will not share information that can identify you with anyone who is not on the study.

What Are the Benefits? There are no direct benefits to you for taking part in this study. The information collected during the study will help CDC better understand how mothers choose to feed their babies and toddlers and can be used to improve the diet of our nation’s children.

What Are My Rights? Taking part in this study is completely voluntary. You can decide not to answer any question or stop participating at any time. There is no penalty for this and it won’t affect any services or other benefits you otherwise get. We will only use the data you have provided up to the point you stop.

Who Should I Call if I Have Questions? If you have questions about the study itself, please contact NAME at STUDY EMAIL OR XXX-XXX-XXXX. If they cannot answer your questions, you may contact Janice Machado, the Project Director at [email protected].

If you have questions about your rights and welfare as a research participant, please call our Human Subjects Protections office at 1-888-920-7631. Follow the directions to leave a message. The office will return your call as soon as possible.

Please type your name below to say:

I have read the information presented here and I agree to take part in Feeding My Baby and Me.

First Name Middle Name Last Name

Date

So we can send you survey invitations, please provide your contact information.

Cell number: _ _ _ - _ _ _ -_ _ _ _ email address: ______________________@_______

Would you prefer to receive study information through text or email or both? (CHECK ALL THAT APPLY)

 Text  Email  Both Text and Email

Please note that if we cannot reach you using your preferred choice, we may switch to the second method.

Once you submit this form, a member of our study team will call you to confirm your study participation. It will take approximately ten minutes. Please check below the best times to reach you.

	Morning (9:00AM – 11:00AM Eastern Time)	Afternoon(12:00PM – 5:00PM Eastern Time)
Monday		
Tuesday		
Wednesday		
Thursday		
Friday		

To submit the consent form, hit the submit button below. A copy of the consent is available on the study web page so you can refer to it at any time. Thank you for agreeing to participate in the Feeding My Baby and Me Study!

SUBMIT

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