Appendix K_Consent form for research participation

Feeding Toddlers Consent Form

OMB Control # 0584-0524 - Expiration Date:9/30/2019
/30/2019
30/2019

Appendix K - Consent form for research participation
This information is being collected to assist the Food and Nutrition Service (FNS) in developing materials used in the Team Nutrition
initiative. This is a voluntary information collection. Under the Privacy Act of 1974 and the FNS System of Record Notice FNS-8, FNS
Studies and Reports, any personally identifying infroamtion obtained will be kept private to the extent of the law. 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 0584-0524. The
time required to complete this information collection is estimated to average 5 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, 3101 Park Center Drive,
Room 1014, Alexandria, VA 22302, ATTN: PRA (0584-0524). Do not return the completed form to this address.

Background& Purpose: You are invited to participate in a research study conducted by Applied
Curiosity Research (ACR) as part of a United States Department of Agriculture, Food and Nutrition
Service sponsored effort to create educational materials about feeding toddlers for Child and Adult
Care Food Program (CACFP) child care sites. Your feedback will help make sure these materials
are clear and engaging for child care providers like yourself across the country.
Process: You will be asked to look through an 8-page handout, which will be mailed to you, prior to
a 30-minute telephone interview with a member of the ACR team. During this interview, you’ll have
the opportunity to provide your thoughts on the materials you reviewed. In addition, during the
interview you’ll receive a link to videos to watch on your phone or computer and will be asked to
give feedback.
Possible Risks & Benefits: We do not anticipate any risks associated with being in this study.
Compensation:Your site will receive a $25 Visa gift card as reimbursement for any needed
resources.
Participant’s Rights: Participation in this study is voluntary. We will not work with you unless you
give your consent. You have the right to change your mind and withdraw 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, email address, and
phone number will only be used to contact you about this research. They will not be given to
anyone else for other purposes.
The research may be audiotaped for research purposes only. Your name will never be used in any
reports of our research findings. Your information will be securely stored on password protected
servers or locked filing cabinets, 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, Gerad O’Shea, by
phone at 212-401-4895 or by email at [email protected].
If you have any questions or complaints about your rights as a research subject, contact:

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Mail:
USDA Food and Nutrition Service
Child Nutrition Programs

Call:
(703) 457-7788

3101 Park Center Drive, Alexandria, VA 22302

Email
teamnutrition@fn
s.usda.gov

1. If you agree to participate, please enter your first name and last name initial below, check “YES” and
then select “SUBMIT”. If you do not agree to participate, please check “NO” below and then select
“SUBMIT” at the bottom of the page.

2. Do you agree to participate in this research?
YES, I have read the above information and agree to participate in this study.
NO, I do not agree to participate in this study.

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