Approved from December 17, 2015 to December, 2016 by the CSULB IRB

CONSENT TO PARTICIPATE IN RESEARCH

Community Leaders Perceptions on Food and Sustainable Urban Agriculture Related to Local
Public Policy
You are asked to participate in a research study conducted by Cindy Tseng, B.S. candidate in
Nutrition and Food Administration, Dr. Virginia Gray, Ph.D., RDN, from Department of Family
and Consumer Sciences at California State University, Long Beach. Research findings will
contribute to undergraduate research project and educational materials for future research related
discussions. You were selected as a possible participant in this study because of your
involvement in community concerns regarding food and related local public policy
PURPOSE OF THE STUDY
To shed light on community leaders perceptions of food availability and related public policy.
PROCEDURES
If you volunteer to participate in this study, you will do the following things:
1. You will meet with a researcher for an interview lasting approximately 1 hour to 1 hours.
2. If needed, you may be asked to participate in a follow up interview ranging from
approximately 1 hour to 1 hours, if needed.
The interviews will take place in a mutually agreed upon location, preferably free from
distractions, loud noises, interruptions, or other factors that may hinder the interview process and
audio recording. Handwritten or typed notes will be recorded during the interview. With your
permission, the interview will be audio recorded. You can still participate in this project if you
choose to not allow for recording. Audio recordings are used to check for accuracy and precision
of data collected and a cross-reference to handwritten or typed notes.
POTENTIAL RISKS AND DISCOMFORTS
A potential risk is that individuals, drawing upon personal knowledge and experiences, may
experience feelings of regret or feel uncomfortable about the state of food as opposed to the ideal
state of food within ones own city.
POTENTIAL BENEFITS TO SUBJECTS AND/OR TO SOCIETY
Results of research may be of benefit to community leaders. Results may provide reasons for
future interventions or programs related food policy and programming.

Approved from December 17, 2015 to December 16 by the CSULB IRB

Approved from December 17, 2015 to December, 2016 by the CSULB IRB

Research findings will contribute to the body of literature for researchers to understand and use
for further research related to food and public policy.
There are no direct benefits to you from participating in this research study.
PAYMENT FOR PARTICIPATION
Interviewees will not receive payment or other form of incentive for participation.
CONFIDENTIALITY
Any information that is obtained in connection with this study and that can be identified with you
will remain confidential and will be disclosed only with your permission or as required by law.
All consent forms and raw data (including handwritten notes) will be destroyed after three years.
We would like to ask for your permission to tape record the interview for ease of analysis. You may
choose to decline audio recording without penalty; in other words, you may still participate in the study
even if you choose to decline the audio recording. If you permit the use of audio recording, you will have
the chance to review, edit, or erase your interview after all other interviews have been completed. All
audio files will be destroyed after transcription.
I agree / decline (please circle one) to be tape recorded during the interview. I have been informed of the
protocol for how the audio files and transcript will be handled after the interview and I understand my
right to review, edit, or erase my interview recording. All of my questions pertaining to audio recording
have been answered.
___________________________________________________

_____________

Signature of Subject

Date

At no time will your actual identity be revealed. You will be assigned a letter code. Anyone who helps me
transcribe responses will only know you by this code. The recording will be erased as soon as it has been
transcribed. The transcript, without your name, will be kept for three years.
The key code linking your name with your number will be kept in a locked file cabinet in a locked office,
and no one else will have access to it. It will be destroyed three years after transcription. The data you
give me will be used as the basis for articles or presentations in the future. I wont use your name or
information that would identify you in any publications or presentations.

PARTICIPATION AND WITHDRAWAL

You can choose whether to be in this study or not. If you volunteer to be in this study, you may
withdraw at any time without consequences of any kind. Participation or non-participation will
not affect your employment status, community leadership status, or any other personal
consideration or right you usually expect. You may also refuse to answer any questions you don't
want to answer and still remain in the study. The Investigator may withdraw you from this
research if circumstances arise which in the opinion of the researcher warrant doing so.
IDENTIFICATION OF INVESTIGATORS
Approved from December 17, 2015 to December 16 by the CSULB IRB

Approved from December 17, 2015 to December, 2016 by the CSULB IRB

If you have any questions or concerns about the research, please feel free to contact:
Cindy Tseng, Principle Investigator

Day Phone: 213-718-2447

Email: cndytsng@gmail.com

Dr. Virginia Gray, Faculty Sponsor

Day Phone: 562-985-4482

Email: Virginia.gray@csulb.edu

RIGHTS OF RESEARCH SUBJECTS

You may withdraw your consent at any time and discontinue participation without penalty. You
are not waiving any legal claims, rights or remedies because of your participation in this research
study. If you have questions regarding your rights as a research subject, contact the Office of
University Research, CSU Long Beach, 1250 Bellflower Blvd., Long Beach, CA 90840;
Telephone: (562) 985-5314. E-Mail: ORSP-Compliance@csulb.edu
SIGNATURE OF RESEARCH SUBJECT
I understand the procedures and conditions of my participation described above. My questions
have been answered to my satisfaction, and I agree to participate in this study. I have been given
a copy of this form.
_________________________________________________
Printed Name of Subject
__________________________________________________
Signature of Subject

____________
Date

STATEMENT and SIGNATURE OF INVESTIGATOR

In my judgment the subject is voluntarily and knowingly giving informed consent and possesses
the legal capacity to give informed consent to participate in this research study.
__________________________________________________
Signature of Investigator

____________
Date

Approved from December 17, 2015 to December 16 by the CSULB IRB