DON'T MISS YOUR Chance
DON’T MISS YOUR
Chance
To Receive a Home Food Delivery Benefit for 24 Months! Have you returned your consent form for Packed Promise? Please send your form to school this week to make sure your child is eligible for the drawing to receive food for 24 months! 5,000 children in selected school districts will receive the Packed Promise food benefit. If you didn’t receive a consent form in your child’s school enrollment packet, please contact the school to get one.
Packed Promise offers a Chance to Receive a Monthly Home Delivery Food Benefit!
Dear Parent or Guardian: We want to help feed your beautiful family! Chickasaw Nation Nutrition Services has an exciting new research project called Packed Promise, funded by the United States Department of Agriculture (USDA). Families in selected school districts in the project will receive a monthly food package shipped directly to their doorstep for 24 months! Also, a $15 FRESH check will be provided to purchase fresh fruits and vegetables at WIC grocery stores located within the Chickasaw Nation. This project will create a fun experience similar to on-line grocery shopping where families choose food items they prefer from a food ordering website or paper catalog. As a bonus, tasty recipes and tips on feeding a happy family will be included! This project has targeted 40 school districts, and a portion of these school districts will be chosen for this project through a lottery (a random selection process which provides an equal chance for every school district) for families to receive the Packed Promise food benefits. Families in the other portion of these school districts will be in the comparison group. • Benefit group – monthly home delivery food package for 24 months and a chance to be selected for three phone surveys. • Comparison group – no food package, but will have a chance to be selected for three phone surveys. To join, simply complete the consent form on the back of this page, sign and return it to your child’s school with your school enrollment packet materials. Packed Promise Details: • Your participation in any aspect of this project is voluntary. Participation or nonparticipation in this project will have absolutely no impact on any government assistance that you and your child may currently receive. • If you agree to participate and are determined eligible, information submitted on the consent form will be given to our research partners, Mathematica Policy Research, USDA and Feed The Children. Over an18-month period, Mathematica may contact you to conduct three phone surveys about the project. Mathematica may also obtain records on your household’s participation in programs such as Summer EBT for Children, SNAP and FDP. This information will not affect your receipt of any benefits or other assistance. • Information provided by you on the consent form or collected during the survey, as well as any records obtained, will be kept private as allowed by law and will be used only for this study. If you have questions about food benefits, please contact the Chickasaw Nation Nutrition Services Packed Promise staff toll free at (844) 230-3785. For questions about your rights as a study volunteer, please contact Bobby Saunkeah with Chickasaw Nation IRB at (580) 421-4562.
CONSENT FORM If you want to join the Packed Promise project, please complete and sign this form and return it to your child’s school with your school enrollment packet materials. PRINT PARENT/GUARDIAN NAME: MAILING ADDRESS: PHYSICAL ADDRESS: MAILING FOR UPS OR FEDEX SHIPMENTS: HOME PHONE NUMBER: WORK PHONE NUMBER: CELL PHONE NUMBER: EMAIL ADDRESS: May we send text messages to your cell phone regarding benefits?:
□ Yes □ No
May Mathematica send text messages to your cell phone regarding the survey?:
□ Yes □ No
Language spoken in home:
□ English □ Spanish
Please print information for each child in your household. If a child is not in school, leave “grade” and “school” blank. If you need more space, continue on a new sheet of paper. First Name
M.I.
Last Name
Gender
Race/Ethnicity
Tribe
Birth Date
Grade
School
If you are in the group receiving the food package, select the week of the month you feel a food package would be most vital to your family:
□ 1st week□ 2nd week□ 3rd week □ 4th week
By signing this consent form you are giving permission to your school district to share the information with Chickasaw Nation Nutrition Services and Mathematica Policy Research. In addition, Chickasaw Nation Nutrition Services and Mathematica Policy Research may also confirm the following details from student records for each child: age, grade, gender, school attended, race/ethnicity, free lunch and language. I have read the information about this research project and understand that I am agreeing to participate in a project focused on helping families feed their children.
Parent Signature
/ / MM / DD / YYYY
Chance
To Receive a Home Food Delivery Benefit for 24 Months! Have you returned your consent form for Packed Promise? Please send your form to school this week to make sure your child is eligible for the drawing to receive food for 24 months! 5,000 children in selected school districts will receive the Packed Promise food benefit. If you didn’t receive a consent form in your child’s school enrollment packet, please contact the school to get one.
Packed Promise offers a Chance to Receive a Monthly Home Delivery Food Benefit!
Dear Parent or Guardian: We want to help feed your beautiful family! Chickasaw Nation Nutrition Services has an exciting new research project called Packed Promise, funded by the United States Department of Agriculture (USDA). Families in selected school districts in the project will receive a monthly food package shipped directly to their doorstep for 24 months! Also, a $15 FRESH check will be provided to purchase fresh fruits and vegetables at WIC grocery stores located within the Chickasaw Nation. This project will create a fun experience similar to on-line grocery shopping where families choose food items they prefer from a food ordering website or paper catalog. As a bonus, tasty recipes and tips on feeding a happy family will be included! This project has targeted 40 school districts, and a portion of these school districts will be chosen for this project through a lottery (a random selection process which provides an equal chance for every school district) for families to receive the Packed Promise food benefits. Families in the other portion of these school districts will be in the comparison group. • Benefit group – monthly home delivery food package for 24 months and a chance to be selected for three phone surveys. • Comparison group – no food package, but will have a chance to be selected for three phone surveys. To join, simply complete the consent form on the back of this page, sign and return it to your child’s school with your school enrollment packet materials. Packed Promise Details: • Your participation in any aspect of this project is voluntary. Participation or nonparticipation in this project will have absolutely no impact on any government assistance that you and your child may currently receive. • If you agree to participate and are determined eligible, information submitted on the consent form will be given to our research partners, Mathematica Policy Research, USDA and Feed The Children. Over an18-month period, Mathematica may contact you to conduct three phone surveys about the project. Mathematica may also obtain records on your household’s participation in programs such as Summer EBT for Children, SNAP and FDP. This information will not affect your receipt of any benefits or other assistance. • Information provided by you on the consent form or collected during the survey, as well as any records obtained, will be kept private as allowed by law and will be used only for this study. If you have questions about food benefits, please contact the Chickasaw Nation Nutrition Services Packed Promise staff toll free at (844) 230-3785. For questions about your rights as a study volunteer, please contact Bobby Saunkeah with Chickasaw Nation IRB at (580) 421-4562.
CONSENT FORM If you want to join the Packed Promise project, please complete and sign this form and return it to your child’s school with your school enrollment packet materials. PRINT PARENT/GUARDIAN NAME: MAILING ADDRESS: PHYSICAL ADDRESS: MAILING FOR UPS OR FEDEX SHIPMENTS: HOME PHONE NUMBER: WORK PHONE NUMBER: CELL PHONE NUMBER: EMAIL ADDRESS: May we send text messages to your cell phone regarding benefits?:
□ Yes □ No
May Mathematica send text messages to your cell phone regarding the survey?:
□ Yes □ No
Language spoken in home:
□ English □ Spanish
Please print information for each child in your household. If a child is not in school, leave “grade” and “school” blank. If you need more space, continue on a new sheet of paper. First Name
M.I.
Last Name
Gender
Race/Ethnicity
Tribe
Birth Date
Grade
School
If you are in the group receiving the food package, select the week of the month you feel a food package would be most vital to your family:
□ 1st week□ 2nd week□ 3rd week □ 4th week
By signing this consent form you are giving permission to your school district to share the information with Chickasaw Nation Nutrition Services and Mathematica Policy Research. In addition, Chickasaw Nation Nutrition Services and Mathematica Policy Research may also confirm the following details from student records for each child: age, grade, gender, school attended, race/ethnicity, free lunch and language. I have read the information about this research project and understand that I am agreeing to participate in a project focused on helping families feed their children.
Parent Signature
/ / MM / DD / YYYY
