Local WIC Agency ___________________ Interviewer ___________________
Interviewed _____________________________
The Food and Nutrition Service (FNS) of the U.S. Department of Agriculture (USDA) is sponsoring a study about WIC food packages and its effect on breastfeeding for WIC participants across the country. Abt Associates Inc. has been hired to conduct the study. You are invited to be part of this study because you have an infant between the age of 30 – 60 days and you receive WIC. Your input is important to help us understand infant feeding and your experience receiving services from WIC. We are asking you to take part in a 30-minute interview with a trained interviewer who will ask you to respond to a set of questions about you and your baby. Here are some things we want you to know about the interview:
Participation in the interview is completely voluntary. Your choice about being in the study will not affect any benefits you may get from the state or federal government, now or in the future.
You may choose to discontinue the interview at any time, for any reason. You may also choose not to answer some of the questions.
After the interview has been completed, you will be given a $35 gift certificate. There will be no other direct benefit to you for participating in this study. The risk may be the discomfort some people feel when expressing their opinions or talking about their experiences.
Any questions you have about the study will be answered before the interview begins.
Any questions you may have after the interview may be directed to Andrea Brand at Abt Associates, Cambridge, MA by calling (800) XXX-XXXX, a toll-free number. Alternately, you can send your questions via email to [email protected].
The study team follows strict rules to protect the privacy of the information you share. All study staff are trained to protect privacy and sign a privacy pledge. All information you provide will be kept private, to the extent allowed by law. Names of women interviewed will not be included in any of the study results.
Your signature below indicates that you understand the above and agree to participate.
Subject’s statement: “The research procedures, risks and benefits have been explained to me. I know that I am free to ask questions. It is my choice to let my child be in the study. I know I can refuse to answer any question or stop being in the study at any time. Being in this study, or not being in it, will not affect any benefits my child or I get from the state or federal government, now or in the future. I know that other questions I may have about the study or about my rights as a subject will be answered by the investigator above. I understand that any information that could be used to identify me will be kept private, except as required by law.”
(Two signed forms: one for the interview participant and one for the interviewer)
| File Type | application/msword |
| File Title | Project Name/ Location ____________________ |
| Author | Andrea Brand |
| Last Modified By | Rgreene |
| File Modified | 2008-10-16 |
| File Created | 2008-10-16 |