Consent Form for Minors

Appendix G: Consent Form for Minors

Usability testing of the National Food Study instrument

Teens Parental Consent to Participate in Research

[for teens younger than 18-years-old]

Purpose. The purpose of this study is to evaluate how teens answer the National Food Study questionnaire items. We are conducting this study under the authority of U.S.C, Title 7 Section 2026 (a) (1) and Section 3171.13 U.S.C. Section 8(b) authorizes the Census Bureau to conduct this study on behalf of USDA.. Federal law keeps your answers confidential (13 U.S.C., Section 9). Your voluntary response will be used to improve the survey instrument. This study is approved by Office of Management and Budget (OMB Control Number: 0607-0725. Approval expires 12/31/2025).

Procedures. If you agree to allow your child to participate, the U.S. Census Bureau will ask your child to complete questionnaire items in the National Food Study, and will also ask debriefing questions that will help us improve the survey instrument. The study may take about 90 minutes.

Confidentiality. The information that your child provides may be used only for statistical purposes and may not be disclosed, or used, in identifiable form for any other purpose except as required by law. Federal law keeps your answers confidential (13 U.S.C., Section 9).). Your child’s name will not be attached to the answers they provide.

Possible Risks and Discomforts. We do not anticipate any risks or discomforts for respondents. However, should your child feel uncomfortable with any question asked, your child may skip the question or stop the interview at any time.

Voluntary Participation. Your child’s participation is completely voluntary. A decision to not participate will not be held against your child. If you agree to allow your child to participate, your child will receive a monetary incentive as a thank-you for their time and input in the study.

Further Questions. If you have questions, please contact Lin Wang, U.S. Census Bureau, Center for Behavioral Science Methods, 301-763-9069

With your permission, the study will be recorded to have an accurate record of your child’s feedback. Direct quotes may be used in reports or in research presentations, but your child’s name will never be used in any reports or presentations. If you do not wish to allow your child to be recorded, your child may still participate in the interview and will still receive the incentive for their participation.

By signing below, you agree that your child, _______________________________, may participate in this study.

Your signature below will indicate that your questions have been answered satisfactorily, and that you have read and understood the information provided above.

___________________________________ ___________________________

Parent’s signature Date

___________________________________

Parent’s printed name

________________________________

Researcher's signature