Parental Permission Form

Appendix E2

Parental Permission Form

Parental Permission for those Parents Whose Children are Participating in Focus Groups (parents are not participating in the groups)

Project: “Formative Research of Adults’ and Childrens’ views Related to Promotion of Healthy Food Choices”

Phases 1 or 2

Project Information and Parental Permission Form

Your child has been asked to take part in a group discussion research project with other children. It will be about ways to speak to children about the foods they eat. Your child’s ideas will help us design and send out messages to help families eat healthy foods.

The discussion will take about an hour and a half to two hours. A trained researcher will lead it. First, the children will get to know each other a little bit. Then they will be asked for ideas about some messages for a program. At the end of the discussion, your child will receive $25. As the parent, you will also receive $25.

Your child being in this study does not mean that he/she or your family is more likely to have poor nutrition. We do not know of any risks to your child being part of this study. Your child will be sharing his or her thoughts and ideas and may find the experience fun.

Your child does not have to take part in the group if he or she does not want to. If he or she takes part, he or she does not have to answer any questions that he or she does not want to answer. Your child can leave the group at any time.

We will audiotape and videotape this group discussion. Some researchers will watch the group. Others may watch or listen to the tapes at a later date. We will transcribe the tapes after the group is over. We do this to make sure that our written report of the discussion is accurate.

All that your child says will be kept private as allowed by law. We will not put your name or your child’s in the report or on the tapes. The tapes will be kept in a locked cabinet. The tapes will be erased by (insert date 12 months from date of focus group). No one outside of this project ill be able to listen to or watch the tapes.

This research is sponsored by the Centers for Disease Control and Prevention. The researcher that leads the discussion is from Alan Newman Research. The Academy for Educational Development is also helping to do this research. If you have any questions about this study, please call Ms. Reba Griffith at 770-488-5548.

If you have questions about your rights or your child’s rights as a participant in this research study or think your child has been harmed, please call the CDC Deputy Associate Director for Science 1-800-584-8814, leave a message including your name and phone number, and someone will call you back as soon as possible.

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Parental Permission Form

I agree to allow my child to take part in this group discussion for research. I have read the Project Information. I understand that the children in the group will talk about what foods they and their families eat. I also agree for my child to be audio- and videotaped and observed.

Parent’s Signature: __________________________________________

Parent’s Name (please print): ____________________________________________

Child’s Name (please print): ____________________________________________

Date: ___________