Individual/Households

L.7 CONSENT FOR ACCESS TO EDUCATION RECORDS

NOTE TO OMB: The Department of Education rule, published on December 2, 2011, at 76 FR 75604-1 amending the Family Education Educational Rights and Privacy Act, 34 C.F.R (“New FERPA Amendment”) provides clarifications to state and local education authorities and agencies regarding if and when the New FERPA Amendment allows disclosure of education records without parental consent. The request for access to education records required for the APEC-II study fits within the New FERPA Amendment's guidelines for exception to parental consent. However, the New FERPA Amendment leaves the discretion for interpreting the New FERPA Amendment with each individual state or local education authority or agency. The form of consent below will be used as the basis for negotiating an appropriate consent with any particular school district that does not deem it appropriate for their school district to provide education records without parental consent.

NATIONAL SCHOOL MEALS STUDY
PARENTAL INFORMED CONSENT FOR DISCLOSURE OF SCHOOL RECORDS

PURPOSE: The U.S. Department of Agriculture (USDA), Food and Nutrition Service (FNS), has contracted with Mathematica Policy Research and its research partners Westat, Inc. and Decision Information Resources to conduct a national study of the National School Lunch Program (NSLP) and School Breakfast Program (SBP). The study will examine issues about participation, eligibility, and certification in the NSLP and the SBP. The information Mathematica collects will help the USDA make decisions about the programs. They want to make sure the federal dollars supporting school meals are reaching children who truly need those meals, and the information is vital to understanding how the programs might be improved.

INFORMATION TO BE COLLECTED: Mathematica randomly selected students from a list of enrolled students provided by your district. The list included households that have applied for the meal program before, as well as those who haven’t. The study would like access to basic information in your child’s school records to match district records with State records. This will help us verify the accuracy of the school meal certification process. You do not have to complete a survey, interview, or provide any other information to us.

Collected information includes student and parent names and address, and student’s gender, race/ethnicity and date of birth.

PRIVACY: The school information about you and your child collected for this study is being used for research purposes only and is private to the full extent provided by law. All information will be grouped with those of other households and will not be shared in a way which can identify you or your child. You or your child will not be identified in reports about the study written by Mathematica.

[Alternative 1 – Passive Consent – This is the preferred approach but is subject to the agreement of each school district requiring parental consent.]

VOLUNTARY PARTICIPATION: Your school district has determined that your passive consent is required for us to have access to the school information for your child described above. You do not have to take part in this study by allowing us to have access to your child’s school information. If you choose not to allow us access to your child’s school records, please return this “opt out” form. Your decision to be in the study is completely voluntary. This study has no identified risks and there are no costs to you for participating in the study. Participation in the study will not affect your eligibility for the school meal program or any other program. It will not directly affect meal reimbursements paid to participating districts and schools or affect meal benefits your household receives, now or in the future. Signing this consent form does not waive any of your legal rights.

STUDY DURATION: We will be collecting data from schools during the 2012 to 2013 school year.

I understand that if I have questions about this study I can call Eric Zeidman___________ at (8XX) XXX-XXXX. If I have questions about my rights as a participant in this study I can call [school district representative name and telephone number].

l have read and understood this entire consent form and I choose to “opt out” of participation in the study.

Child’s Name (Please Print): _____________________________________________

Parent’s Name (Please Print): ____________________________________________

Parent’s Signature: ______________________________ Date: ________________

[Alternative 2 – Active Consent]

VOLUNTARY PARTICIPATION: Your school district has determined that your consent is required for us to have access to the school information for your child described above. You do not have to take part in this study by allowing us to have access to your child’s school information. Your decision to be in the study is completely voluntary. This study has no identified risks and there are no costs to you for participating in the study. Participation in the study will not affect your eligibility for the school meal program or any other program. It will not directly affect meal reimbursements paid to participating districts and schools or affect meal benefits your household receives, now or in the future. Signing this consent form does not waive any of your legal rights.

STUDY DURATION: We will be collecting data from schools during the 2012 to 2013 school year.

l have read and understood this entire consent form. I understand that if I have questions about this study I can call Eric Zeidman___________ at (8XX) XXX-XXXX. If I have questions about my rights as a participant in this study I can call [school district representative name and telephone number].

I agree to participate in this study, and will allow Mathematica to collect information in my child’s school records and use it for research purposes only, as described in this form.

Child’s Name (Please Print): _____________________________________________

Parent’s Name (Please Print): ____________________________________________

Parent’s Signature: ______________________________ Date: ________________

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 collection is 0584-0530. The time required to complete this information collection is estimated to average 3-5 minutes per response, including the time to review instructions, searching existing data resources, gather the data needed, and complete and review the information collected.

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