Attachment F2 - Parental Consent Form

Status: Original and derived artifacts are available for this document.

Download: docx | pdf | html

Attachment F2. Parental Consent Form

Parental Consent Form

OMB Control Number: xxxx-xxxx 
Expiration Date: xx/xx/xxxx 

You are being asked to allow your child to participate in the National Food Study (NFS) Pilot. Please read the following information carefully before you decide whether or not you consent to allow your child to participate. 

Sponsor of Study: The study is sponsored by the U.S. Department of Agriculture (USDA) under the authority of United States Code Title 7 Section 2026 (a) (1). The study is conducted by Westat, an independent research firm. 

Purpose of the study: This study will collect information to help USDA improve food choices and food quality and help to assure that all residents of the US have access to a healthy diet at affordable prices. 

Procedures to follow: If you agree to your child participating, we will ask your child to review videos on how to participate, complete a profile questionnaire and keep track of the foods and drinks and meals and snacks for 7 days. If your child uses the study’s smartphone app. to tell us about their Food and Drinks, we will ask for your permission to track the locations your child goes to during the study week. Children 16 years and older are asked to complete an income questionnaire. Alternatively, you can report for minors in your household. 

Incentives and Time to Take Part: The incentives your child gets for participating will be added to your family’s incentives. The incentives for completing each survey activity are in the table below1. 

Task
Training on Reporting Food and Drinks
Reporting Foods and Drinks
Income Questionnaire
Profile Questionnaire
Incentive
$0
$35/child
$2
$2/child
Minutes
45 mins./child 11 years and older 
9 mins./child/day 
15 mins./child 16 years and older
 3 mins./child
 
Voluntary participation: Taking part in the study is voluntary. If you choose to participate, your child can skip any question he or she does not want to answer or that makes him or her feel uncomfortable. Deciding to take part in the study or not, or withdrawing from the study, will not affect your eligibility for benefits or services received by anyone in your household—now or in the future. Each household member may decide to participate. Your household may participate even if some but not all members agree to participate. 

Risks and Benefits: The risks are no greater than those ordinarily encountered in daily life. If you receive government benefits, the study incentives will not affect your eligibility or benefit amount. There are no direct benefits to participating in this study.

Termination of participation: Your child may choose not to participate in the study at any time. If your child withdraws before tracking foods for 7 days, he or she will receive only the study incentives for the period of his or her participation in the study. The study may use the data provided to us up to the time of withdrawal. 

Statement of confidentiality: We are required by law (read box below) to use your information for statistical research only and to keep it confidential. The law prohibits us from giving anyone any information that may identify you or your family without your consent.

Assurance of Confidentiality: The USDA, its employees, agents, and partner statistical agencies, will use the information you provide for statistical purposes only and will hold the information in confidence to the full extent permitted by law. In accordance with the Confidential Information Protection and Statistical Efficiency Act of 2002 (Title 5 of Public Law 107-347) and other applicable Federal laws, your responses will not be disclosed in identifiable form without your informed consent. Per the Federal Cybersecurity Enhancement Act of 2015, Federal information systems are protected from malicious activities through cybersecurity screening of transmitted data.

If you have questions about this research, please contact Janice Machado, the Project Director at (301-294-2801; [email protected]) 

If you have questions about your rights and welfare as a research participant, please call the Westat Human Subjects Protections office at 1-888-920-7631. Please leave a message with your full name, mention that you are calling about the National Food Study, and leave a phone number beginning with the area code. Someone will return your call as soon as possible.

I have read the information provided on this form. By providing an electronic signature and date I show that I am the parent or legally authorized representative and I agree to have my minor children take part in this study.