Appendix C_Consent Package for Teacher of Health Education Survey

OMB Control # 0584-0524

Expiration Date: xx/xx/20xx

Appendix C – Teacher Letter, Teacher Informed Consent Form for Survey Participation (Consent Package for Teacher of Health Education Survey)

OMB BURDEN STATEMENT: This information is being collected to assist the Food and Nutrition Service (FNS) in providing the public with information concerning its child nutrition programs. This voluntary information will be used to develop nutrition education resources and interventions for population groups served by FNS. Under the Privacy Act of 1974, any personally identifying information obtained will be kept private to the extent provided by law. According to the Paperwork Reduction Act of 1995, no persons are 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 0584-0524. The time to complete this information collection is estimated as part of the 5 minutes for the screener, including the time for reviewing instructions and completing the 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 (0584-0524). Do not return the completed form to this address.

[DATE], 2016

Dear Educator,

Thank for you choosing to complete this brief survey about your experiences using technology to support nutrition education and promotion in your school. Before you complete this survey, please read the consent form that explains the project and provides information about your rights as a research participant.

Sincerely,

[Researcher]

OMB BURDEN STATEMENT: This information is being collected to assist the Food and Nutrition Service (FNS) in providing the public with information concerning its child nutrition programs. This voluntary information will be used to develop nutrition education resources and interventions for population groups served by FNS. Under the Privacy Act of 1974, any personally identifying information obtained will be kept private to the extent provided by law. According to the Paperwork Reduction Act of 1995, no persons are 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 0584-0524. The time to complete this information collection is estimated as part of the 5 minutes for the screener, including the time for reviewing instructions and completing the 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 (0584-0524). Do not return the completed form to this address.

Teacher Informed Consent Form for Survey Participation

STUDY TITLE: Educational Technology Environmental Scan

PROTOCOL NUMBER: XXXX

PRINCIPAL INVESTIGATOR:	Marha Hadley, Ph.D.
TELEPHONE:	212-431-2252
ADDRESS:	Michael Cohen Group LLC 375 West Broadway, Suite 502 New York, NY 10012

BACKGROUND AND PURPOSE:

You are invited to participate in a research study conducted by Michael Cohen Group (MCG) as part of a United States Department of Agriculture (USDA) sponsored effort understand the landscape of technology in K-12 schools. MCG is an education research firm that specializes in children, education, and media.

We are interested in learning about how teachers of health education use technology to support nutrition education and promotion in K-12 schools, in order to develop new technologies, programs, and materials that are convenient and useful for teachers. If you agree to participate, you will be asked about your attitudes about and experiences with educational technology.

PROCEDURES:

You will be asked to answer survey questions about your experiences with and attitudes about technology, as well as the challenges, benefits, barriers, and best practices associated with using technology to support nutrition education and promotion. The survey will take about 10 minutes to complete online. About 119 teachers will participate in total across the country.

POSSIBLE RISKS AND BENEFITS:

We do not anticipate any risks associated with being in this study. We do not promise that you will receive any benefits from this study. However, we do anticipate that most people will enjoy participating in the research process and the research will eventually lead to the development of free teacher resources that will be developed by the USDA.

COMPENSATION:

You will not receive monetary compensation for your participation.

PARTICIPANTS’ RIGHTS:

Participation in this study is voluntary. You do not have to complete the survey unless you give your consent. You have the right to change your mind and withdraw your consent or discontinue participation at any time without any penalty or loss of the benefits to which you are otherwise entitled. You have the right to refuse to answer particular questions.

Your name and email address will never be used in any reports of our research findings, nor will it be associated in any way with your responses. Your information will be kept secure and only used for research purposes, except as otherwise required by law. All data will be identified only by an ID number, not by any name.

CONTACT INFORMATION:

If you have any questions, concerns or complaints about this research study, its procedures, risks and benefits, please contact the Principal Investigator, at the telephone number listed on the first page of this form.

If you have any questions or complaints about your rights as a research subject, contact:

• Mail:

Study Subject Adviser

Chesapeake Research Review, Inc.

7063 Columbia Gateway Drive, Suite 110

Columbia, MD 21046

• Call collect: 410-884-2900

• Email: [email protected]

CONSENT:

Based on the information provided above, please read the following statements and select whether you agree to participate in the study. If you select “Yes, I agree to participate”, you will be immediately directed to the survey.

Yes, I, agree to participate in this research project with the Michael Cohen Group. I understand that I may stop participation at any time.

No, I do not agree to participate in this research project with the Michael Cohen Group.