Appendix A

Child Informed Consent Form

You have been invited to participate in a Senior Research Project conducted by                       a student at LCSC in collaboration with                    Elementary School.  Your parent/guardian has approved for you to participate if you choose to do so.  The goal of the project is to determine how much knowledge 10 to 12 year old girls retain on Nutrition and Body Image Education.  The project will consist of group discussions about My Pyramid and Body Image curriculum and questionnaire's regarding these two topics.  There will be three lessons included in the curriculum, one involving MyPyramid for Kids and the other two relating to body image.  MyPyramid is a research based nutrition education program developed by the United States Department of Agriculture.  The lessons incorporate math, language arts, music and art into nutrition based lessons.  The body image lessons come from the workbook, Challenging the Barbie Doll Syndrome.  This work book is designed to help girls think critically about societal messages to be thin.  The classes will be held during normal group time for 3 weeks.  The participants will take 2 surveys before the first class.  These tests are the nutrition survey and the self-esteem survey.  Each survey will take approximately 10 minutes each.  A second set of surveys will be given at the completion of the 3 lessons and a third set of the same surveys will be given 2-4 weeks after completing the lessons.  Your participation in this project is completely voluntary.  If you choose not to participate, you can attend the classes without completing the surveys. Any risks are considered to be minimal or non-existent. However, if you feel uncomfortable participating or answering any questions, you can withdraw from the project at any point and speak to                                                                               NOTE: YOU WILL ADD THE SUPERVISOR AND STUDENT INFORMATION HERE.  Responses on the surveys will not have your name on them or identify you in any way.  Please take the time to check the yes or no box, sign the consent form, and return it to             . If you require assistance or have any questions regarding this project please feel free to contact NOTE: YOUR CONTACT INFO HERE INCLUDING LCWARRIORMAIL AND SCHOOL AGENCY/SCHOOL CONTACT or Dr. Brian L. Christenson at (208) 792-2476 or blchristenson@lcsc.edu.  Should you have further questions regarding your rights, you may contact the Institutional Review Board of LCSC at (208) 792-2461. Thank you very much for your time.

___  Yes, I want to participate in the Research Project.

____ No, I do not want to participate in the Research Project.

_____________________________                                           

Participant’s Name           

NOTE: Please feel free to copy this information and modify to your study.

Dr. Christenson