Individual/Households

N

OMB Approval No.: 0584-0530

Approval Expires:

L.5 INFORMED CONSENT FOR PARTICIPATION

ATIONAL SCHOOL MEALS STUDY
INFORMED CONSENT FOR PARTICIPATION

PURPOSE: The U.S. Department of Agriculture (USDA), Food and Nutrition Service (FNS), has contracted with a study team of Mathematica Policy Research, Westat and Decision Information Resources to conduct a national study of the National School Lunch Program (NSLP) and School Breakfast Program (SBP). The study will address issues about access, participation, eligibility, and certification in the NSLP and the SBP. It will help USDA better understand the school meal programs and whether the benefits are being received as intended.

INFORMATION TO BE COLLECTED: The study team randomly selected students from application forms for free or reduced-price meals submitted to the school district and from students directly certified for free meals through their participation in other assistance programs. Interviews will be conducted with parents in their homes about their experiences with the school food program. The study team will also collect information recorded on the application forms, changes in meal certification status, changes in enrollment status, and program participation at schools that keep participation information on individual students.

STUDY DURATION: The survey and participation information data collection will be during the 2012-2013 school year.

RISKS: This study has no identified risks.

STUDY COSTS AND COMPENSATION: There are no costs to you for participating in the study. You will be given a $25.00 gift card as a token of appreciation for completing the survey.

PRIVACY: The information about you and your child collected for this study is being used for research purposes only and is private to the full extent allowed by law. Your responses will be grouped with those of other households and will not be shared with your child’s school, school district, or the USDA in a way which can identify you or your child. You or your child will not be identified in reports about the study. Participation in the study will not affect your eligibility for the school meal program or any other program. It will not affect meal reimbursements paid to participating districts and schools or affect meal benefits your household receives.

VOLUNTARY PARTICIPATION: You do not have to take part in this study. Your decision to be in the study is completely voluntary. Signing this consent form does not waive any of your legal rights.

l have read and understood this entire consent form. I have been given the chance to ask questions about the study and all my questions have been answered to my satisfaction. I understand that if I have other questions about this study I can call Eric Zeidman, the study survey director, toll-free 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 the study team to collect eligibility information for free and reduced-price meals including any application I submitted, my child’s school breakfast and lunch program participation, changes in my child’s meal certification status, and changes in my child’s school enrollment status.

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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