G15. Parent Consent and Permission Form (Children)
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Study of Nutrition and Activity in Child Care Settings II (SNACS-II)
Parent Consent and Permission Form for Children
The U.S. Department of Agriculture (USDA) invites you and your child to be a part of the second Study of Nutrition and Activity in Child Care Settings (SNACS-II). This form explains what it means to be in the study. Please read, sign and return this form. You can submit it online or mail it in the stamped envelope.
What is SNACS-II?
Your child’s child care provider is part of this national study. The study will look at the food and activities provided to infants, children, and youth in a sample of over 1,300 child care centers, family child care homes, and before-and-after-school programs across the country. The study will include over 4,000 infants, children, and youth, and their parents/guardians, from these providers. Part of the study will look at the physical activity and foods eaten by children in these programs. This important study will help child care providers and the USDA understand how the Child and Adult Care Food Program (CACFP) operates so that it can better help children learn and grow. Mathematica and Westat are conducting the study for the USDA.
What is expected of me and my child?
If you agree to be in the study, we will ask you to participate in [two/three] telephone interviews. These interviews will ask about the food your child eats outside of child care and their physical activity. We will ask you to help describe your child’s food and drinks using a Child Food Diary and a Food Model Booklet. We will mail these to you. We will send you a gift card after you complete each telephone interview. You will receive $20 after the first interview and $30 after the second interview. [You will receive another $30 gift card after you complete the third interview.]
With your written permission, a professional data collector will observe your child’s meals and activities during the time that your child is in child care. A professional data collector will measure your child’s weight and height at the child care center/home. Staff will help with this. Data collectors will never be alone with your child. All equipment will be thoroughly cleaned and sanitized.
Will information collected about me and my family be kept private?
All information gathered for the study is private under the Privacy Act to the extent allowed by law. We will not share any information that identifies children or family members with anyone outside of the study. We will remove all identifying information from the data during analyses. All the reports will present the findings in groups. The names of children and family members will never appear in any report or with any study findings. Any forms or other papers that include your name will be kept in a locked storage area. Any computer files with your name will be locked and protected. Any researchers using information to study the program must follow all data security rules.
Are there any risks or benefits?
Although there is no direct benefit to you, findings from the study will help USDA and child care providers improve children’s health, wellness and learning. There is a very small risk of loss of confidentiality, but the study team has taken many steps to reduce this risk.
Is the study voluntary?
Yes, taking part in the study is voluntary. It is your choice to be in this study or not. You may change your mind at any time about being in the study. In addition, you and your child may opt out of any of the data collection activities or skip any questions that you do not want to answer. Participating in the study will not affect your child care or any other services that you or your family receives or may apply for in the future. Signing this consent form does not waive any of your legal rights.
The
Food and Nutrition Service (FNS) is collecting this information to
understand the nutritional quality of CACFP meals and snacks, the
cost to produce them, and dietary intakes and activity levels of
CACFP participants. This is a voluntary collection and FNS will use
the information to examine CACFP operations. The collection does
request personally identifiable information under the Privacy Act of
1974. Responses will be kept private to the extent provided by law
and FNS regulations. 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 0.167
hours (10 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, 1320 Braddock Place, 5th Floor, Alexandria, VA 22314. ATTN:
PRA (0584-xxxx). Do not return the completed form to this address.
CONSENT
I have read the information about this study, including this entire consent form. I understand that I am being asked to participate in a voluntary study.
I have been given the chance to ask questions about the study and all my questions have been answered to my satisfaction.
I will return this form in the enclosed stamped envelope or submit it on the study website.
YES, I agree to be in the study and agree that my child can participate in the study. |
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Parent/Guardian Signature (or type in) |
MM DD YYYY |
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Parent/Guardian Name: |
Email Address: |
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Address (Street, City, State): |
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Primary Telephone Number: __ __ __ -__ __ __- __ __ __ __ □ Cell □ Home |
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Best time to call: □ Morning □ Afternoon □ Evening □ Anytime |
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Can we send you text messages for the study? □ Yes □ No |
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Alternate Telephone Number: __ __ __ -__ __ __- __ __ __ __ □ Cell □ Home |
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What days of the week does your child usually attend child care at this facility during the school year (August-May)? (Check all that apply.) □ Mondays □ Tuesdays □ Wednesdays □ Thursdays □ Fridays □ Saturdays □ Sundays |
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Child’s Name: [sampled child’s name] |
Child’s Gender: □ Female □ Male |
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Child’s Date of Birth: | | |/| | |/| | | | | MM DD YYYY |
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Would you like a copy of this form to be sent to your email? □ Yes □ No |
NO, I do not agree to be in the study. |
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Parent/Guardian Signature (or type in) |
MM DD YYYY |
Parent/Guardian Name: |
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Would you like a copy of this form to be sent to your email? □ Yes □ No |
File Type | application/vnd.openxmlformats-officedocument.wordprocessingml.document |
Author | Mathematica |
File Modified | 0000-00-00 |
File Created | 2022-03-21 |