G5_Parent Consent and Permission Form (Infants)

G5. Parent Consent and Permission Form (Infants)

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Study of Nutrition and Activity in Child Care Settings II (SNACS-II)

Parent Consent and Permission Form for Infants

The U.S. Department of Agriculture (USDA) invites you and your infant to be a part of the second Study of Nutrition and Activity in Child Care Settings (SNACS-II). This form explains what it means to be in the study. Please read, sign and return this form. You can submit it online or mail it in the stamped envelope.

What is SNACS-II?

Your infant’s child care provider is part of this national study. The study will look at the food and activities provided to infants, children, and youth in a sample of over 1,300 child care centers, family child care homes, and before-and-after-school programs across the country. The study will include over 4,000 infants, children, and youth, and their parents/guardians, from these providers. Part of the study will look at infant feeding practices, infant food intake, and infant activity levels while in child care. This important study will help child care providers and the USDA understand how the Child and Adult Care Food Program (CACFP) operates so that it can better help children learn and grow. Mathematica and Westat are conducting the study for the USDA.

What is expected of me and my infant?

If you agree to be in the study, your infant’s child care provider will complete a form about what your infant eats and drinks on one day when your infant is in care. We will ask you to provide your infant’s date of birth and their weight at the time of their last medical visit on this form.

Will information collected about me and my family be kept private?

All information gathered for the study is private under the Privacy Act to the extent allowed by law. We will not share any information that identifies children or family members with anyone outside of the study. We will remove all identifying information from the data during analyses. All the reports will present the findings in groups. The names of children and family members will never appear in any report or with any study findings. Any forms or other papers that include your name will be kept in a locked storage area. Any computer files with your name will be locked and protected. Any researchers using information to study the program must follow all data security rules.

Are there any risks or benefits?

Although there is no direct benefit to you, findings from the study will help USDA and child care providers improve children’s health, wellness and learning. There is a very small risk of loss of confidentiality, but the study team has taken many steps to reduce this risk.

Is the study voluntary?

Yes, taking part in the study is voluntary. It is your choice to be in this study or not. You may change your mind at any time about being in the study. In addition, you may opt out of any of the data collection activities or skip any questions that you do not want to answer. Participating in the study will not affect your child care or any other services that you or your family receives or may apply for in the future. Signing this consent form does not waive any of your legal rights.

Questions about the study?

The Food and Nutrition Service (FNS) is collecting this information to understand the nutritional quality of CACFP meals and snacks, the cost to produce them, and dietary intakes and activity levels of CACFP participants. This is a voluntary collection and FNS will use the information to examine CACFP operations. The collection does request personally identifiable information under the Privacy Act of 1974. Responses will be kept private to the extent provided by law and FNS regulations. 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-xxxx. The time required to complete this information collection is estimated to average 0.167 hours (10 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 22314. ATTN: PRA (0584-xxxx). Do not return the completed form to this address.

If you have any questions, please call our toll-free study hotline at [telephone number] or send an email to [study email address]. If you have any questions about your rights as a research participant, please call [IRB telephone number].

CONSENT

• I have read the information about this study, including this entire consent form. I understand that I am being asked to participate in a voluntary study.

• I have been given the chance to ask questions about the study and all my questions have been answered to my satisfaction.

• I will return this form in the enclosed stamped envelope or submit it on the study website.

YES, I agree to be in the study.
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Parent/Guardian Signature (or type in)	MM DD YYYY
Parent/Guardian Name:		Email Address:
Address (Street, City, State):
Primary Telephone Number: __ __ __ -__ __ __- __ __ __ __ □ Cell □ Home
Best time to call: □ Morning □ Afternoon □ Evening □ Anytime
Can we send you text messages for the study? □ Yes □ No
Alternate Telephone Number: __ __ __ -__ __ __- __ __ __ __ □ Cell □ Home
What days of the week does your infant usually attend child care at this facility during the school year (August-May)? (Check all that apply.) □ Mondays □ Tuesdays □ Wednesdays □ Thursdays □ Fridays □ Saturdays □ Sundays
Infant’s Name: [sampled child’s name]		Infant’s Gender: □ Female □ Male
Infant’s Date of Birth: | | |/| | |/| | | | | MM DD YYYY
How much did your infant weigh at the time of their last medical visit? | | | pounds and | | | ounces
What was the date of your infant’s last medical visit? | | |/| | |/| | | | | MM DD YYYY
Would you like a copy of this form to be sent to your email? □ Yes □ No

NO, I do not agree to be in the study.
	| | |/| | |/| | | | |
Parent/Guardian Signature (or type in)	MM DD YYYY
Parent/Guardian Name:	Email Address:
Would you like a copy of this form to be sent to your email? □ Yes □ No