Appendix L - Screener for research participation clean 09062019

Feeding Toddlers Questionnaire

OMB Burden: 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 3 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.

Thank you for signing up to give feedback on free handouts and videos for Child and Adult Care
Food Program (CACFP)child care sites.
As a reminder, Applied Curiosity Research (ACR) is working with the United States Department of
Agriculture, Food and Nutrition Service (FNS) to create a handout and videos to help child care
sites with the updated CACFP guidelines for feeding toddlers. ACR is gathering feedback from child
care providers and directors across the country to make sure these materials are clear and
relevant.
If you are eligible to participate your responsibilities will include:
Step 1: Look through an 8-page handout (these materials will be mailed to you)
Step 2: Complete a 30-minute phone conversation with a member of the ACR team
Step 3: Click on a link during our interview to watch a few 1-2 minute videos on your phone or
computer and give feedback on these videos
Step 4: We will send you $25 for your time.
Please note that your information will be kept private and not shared with anybody outside of our
project team for any reason other than required by law.
1. If you are still interested in participating, click the following button to complete a brief questionnaire:
I'm Interested
I'm not Interested

Please complete the following questionnaire honestly to see if you are eligible to
participate in this project.
2. What is your role at your current child care site?
Site Director
Lead Classroom Provider
Assistant Classroom Provider
Classroom Aide
Other (please specify)

3. How many years have you been working in child care?
First year

11-15 years

1-5 years

Over 15 years

6-10 years

4. How old are the children in your classroom? If you are a director, please select the ages of children your
site serves. (Select all that apply).
Less than 12 months old
12 months-24 months
25 months – 36 months
48 months and older

5. What is your current age?
Under 25

45-54

25-34

55+

35-44

6. Do you currently consider yourself male, female, or transgender?
Female
Male
Transgender
Other (please specify)

7. What is your ethnicity?
Hispanic or Latino
Not Hispanic or Latino

8. What is your race?
American Indian or Alaska Native
Asian
Black or African American
Native Hawaiian or Other Pacific Islander
White

9. The handouts will be in English and Spanish, and we’re looking for participants to review them in both
languages. Are you able to read and speak Spanish fluently?
Yes
No

10. We want to make sure Spanish speakers from different cultures like the handouts and can relate to
them. Which of the following best describes your Hispanic origin?
Mexican
Cuban
Puerto Rican
Other (please specify)

Contact Information

11. If you are selected, we will call you to schedule a date and time for an interview. Please provide your
contact information below. We will only contact you about this research.
First Name and Last
Initial
Cell Phone Number
Email Address

Thank you for signing up to give us your feedback on the free CACFP materials about feeding
toddlers! There is nothing more you need to do at this time.
If you are eligible for the interview, a member of the research team will call you by [date] to
schedule your interview.
We’re still looking for other child care providers and directors to speak with. Please share the
following link with others who may be interested at your site [link].
Privacy Act Statement
Authority: Section 9 of the Food and Nutrition Act of 2008 (as amended through P.L. 113-27) and federal statutes 7 U.S.C. 2011-27;
42 U.S.C. 1751-89; and 7 U.S.C. 1431, 1431e, 612c, and 612c authorize the collection of name, gender, race, ethnicity, and contact
information in researching and evaluating nutrition assistance programs.
Purpose: Information is collected exclusively for use by Applied Curiosity Research on behalf of the Food and Nutrition Service of the
US Department of Agriculture for scheduling and informing participants about research activities and to ensure diverse participants are
included in the research.
Routine Use: Information will only be used to determine eligibility for research participation and contact participants to schedule
research activities. Please see System of Record Notice FNS-8, FNS Studies and Reports, published in the Federal Register on
4/25/1991 at 56 FR 19078.
Disclosure: Furnishing the information on this form is voluntary, but failure to provide any contact information will result in withdrawal
from participation in the focus group interview.
Citation: Privacy Act, 5 U.S.C. § 552a (1974) Please note that your information will be kept private and not shared with anybody outside
of our project team for any reason other than required by law.