Attachment J Confidentiality Agreement

ATTACHMENT J – CONFIDENTIALITY AGREEMENT

The confidentiality agreement will be translated in Spanish after OMB approval for this package has been obtained. A FH/GMMB subcontractor will translate the agreement.

OMB Burden Statement: Public reporting burden for this collection of information is estimated to average two hours and 20 minutes per response, including the time for reviewing instructions, searching existing data sources, gathering and maintaining the data needed, and completing and reviewing the collection of information.  An agency may not conduct or sponsor, and a person is not required to respond to, a collection of information unless it displays a currently valid OMB control number.  Send comments regarding this burden estimate or any other aspect of this collection of information, including suggestions for reducing this burden, to: U.S. Department of Agriculture, Food and Nutrition Services, Office of Research, Nutrition and Analysis, Alexandria, VA 22302 (0584-0524).  Do not return the completed form to this address.

Food Stamp Program

Opinion surveys, written notes by observers, and audiotape recordings created by a research study are called research records. The research records that will be collected and used for this study may include an opinion survey, written notes, and an audiotape made during your participation in the focus group discussion. However, your comments and survey responses will be shared only in the aggregate with those from the other participants within the written report. (The focus group project director, an employee of an independent research company, Fleishman-Hillard Research, will maintain possession of the research records and will destroy them upon completion of the written research report.)

Aggregated information/results from this study and portions of audio recordings (with no identification of individuals by name) may be presented in meetings or oral presentation to the USDA Food and Nutrition Service. Your name, and any information that can be traced back to you, will not be included in any reports or meetings.

I understand that all information revealed during this interview or focus group (LOCATION/DATE/TIME) will be held strictly confidential by the research team collecting this information. I understand that my name will not be used in any meetings or reports regarding the focus group discussions.

Signature of Participant Date

Name of Participant (please print)