C25a. (Recruitment 025) Household Consent form_Virtual Survey_v3_English

Appendix C25. Household Consent Form—Virtual Survey

OMB Number: 0584-0530

Expiration Date: xx/xx/20xx

National School Meals Study (NSMS)

Household Survey Consent Form

______________________________________________________________________________

PURPOSE: The United States Department of Food and Agriculture (USDA), Food and Nutrition Service (FNS) funds the National School Lunch and School Breakfast programs. These programs help schools in providing nutritious meals to children. The USDA is conducting a series of studies to gather up-to-date information about these programs, including: a) who they serve, b) how participants feel about the meal services they receive, and c) how eligibility for program participation is collected and reported. Through this study, USDA FNS wants to know more about how school meals are served and how schools determine household eligibility and report meal claims to the USDA. This Study includes a household survey conducted by a research organization, Westat.

HOW YOU WERE SELECTED: Your household was chosen randomly from a list of households from your school.

INFORMATION TO BE COLLECTED: As the parent, or guardian, you will be asked about your child’s experience with the breakfast and lunch programs provided by your school, as well as household size and income information used to determine eligibility for meal benefits. We will give you a worksheet to prepare for the survey before talk with you. The survey will take place virtually via video call. It is your choice to use the video or not (you can also call in using your phone). We will schedule the call at a time that you prefer.

RISKS AND PRIVACY: There is little risk to being part of this study. We use all data we collect only for the purposes we describe. Many steps are taken to keep your data private to the full extent allowed by law. Any reports we prepare will combine your answers with those from other people in the study to summarize what we found. Your name, your child’s name, and your contact information (e.g., phone number and address) will never be in the reports we prepare. Nothing you say is shared with the school your child attends or any agency that provides benefits to your household. Participating in the study may not help you individually, but your participation will help the USDA improve the National School Lunch and School Breakfast programs.

STUDY COSTS AND COMPENSATION: There is no cost to you to join this study. The interview takes about 45 minutes. As a thank you, you can receive up to a $60 Visa gift card, depending on the tasks you complete. You will get a $40 Visa gift card for completing the survey and you will get an extra $20 on the gift card if you also provide the documents to verify your income.

VOLUNTARY PARTICIPATION: You do not have to take part in this study. It is your choice to be in this study or not. You may skip any question you do not wish to answer, and you can stop the interview at any time. Signing this consent form does not waive any of your legal rights. If you do not participate, you will not lose any benefits you may receive. Also, it will not impact any benefits the school district receives.

QUESTIONS: If you have questions now, you should talk to the interviewer. If you have questions about the study later, you may call Roline Milfort, the study project director, toll-free at <Toll Free Number>, or visit our study’s website at <URL>. If you have questions about your rights as a research participant, please call the Westat Human Subjects Protections office at <Toll Free Number>. Please leave a message with your full name, the name of this study (NSMS), and a phone number including the area code. Someone will return your call as soon as possible.

CONSENT SIGNATURES: I have been given the chance to ask questions about the study and all my questions have been answered to my satisfaction. I have read and understand this entire consent form, and agree to participate in this study.

Authority: This information is being collected under the authority of the Healthy, Hunger-Free Kids Act of 2010 (P. L. 111-296), Section 305.

Purpose: The Food and Nutrition Service (FNS) is collecting this information to assess improper payments made in the National School Lunch Program (NSLP) and School Breakfast Program (SBP).

Routine Use: The records in this system may be disclosed to private firms that have contracted with FNS to collect, aggregate, analyze, or otherwise refine records for the purpose of research and reporting to Congress and appropriate oversight agencies, and/or departmental and FNS officials.

Disclosure: Disclosing the information is voluntary, and there are no consequences to you as an individual for not providing the information. 

The System of Records Notice for this information collection is USDA/FNS-8, FNS Studies and Reports, which can be located at https://www.govinfo.gov/content/pkg/FR-1991-04-25/pdf/FR-1991-04-25.pdf (p. 19078).

This information is being collected to provide the Food and Nutrition Service with key information on the annual error rates and improper payments for the school meal programs. This is a voluntary collection and FNS will use the information to examine school meal error rates and inform future APEC studies. This collection requests personally identifiable information under the Privacy Act of 1974. 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 0584-0530. The time required to complete this information collection is estimated to average 0.0334 hours (2 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 22306 ATTN: PRA (0584-0530). Do not return the completed form to this address.

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