Consent Form - Participants

OMB Number: 0584-0484
Expiration Date: XX/XX/20XX

APPENDIX A
A-1 MACRO CONFIDENTIALITY PLEDGE
A-2 HOUSEHOLD INTERVIEW CONSENT FORM
A-3 FEDERAL REGISTER NOTICE

OMB Number: 0584-0484
Expiration Date: XX/XX/20XX

APPENDIX A-1: MACRO CONFIDENTIALITY PLEDGE
Public reporting burden for this collection of information is estimated to average 2 minutes per
response, including the time for reading instruction, asking questions and filling the form out. 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 and Analysis, Room 1014, Alexandria, VA 22302 ATTN: PRA (0584-0484).
Confidentiality Pledge
I, Data Collector Name, in my role as an employee of Hiring Subcontractor Name, working as
a Field Interviewer for the National Survey of WIC Participants II study, Macro contract
Contract: GS-23F-9777H (Order: AG-3198-D-07-0105), understand and agree to comply with
the following:
Confidentiality of Data
All information I obtain, from either formal interviews or in casual observation or conversation,
will be treated as confidential and not discussed with any parties not authorized to have access to
such data, including (but not limited to) WIC agency staff, other households I may contact, and
USDA/FNS staff.
Support for Goals of Study/Objectivity
I support the goals of this study and will collect, to the best of my ability, complete and accurate
data, and will report the data objectively and without regard to how it might affect the results of
this study. I will be objective in all dealings with study participants. I will voice no opinions I
may have about WIC participants and how the WIC program is administered, and I will not
discuss them with any study participants (including WIC local agency staff and households).
Treatment of Hardcopy Documents
All information I obtain, from hardcopy documents will be treated as confidential and will not be
discussed with or shown to any parties not authorized to have access to such information,
including (but not limited to) project staff, other households I may contact, local WIC agency
staff, and USDA/FNS staff.
My signature below signifies my agreement with the above stipulations.

Data Collector Signature: ______________________________
Date:_______________________________________________

OMB Number: 0584-0484
Expiration Date: XX/XX/20XX

National Survey of WIC Participants II Household Interview Consent Form – 2009
Public reporting burden for this collection of information is estimated to average 3 minutes per response, including the time for
reading text, asking questions and signing document. 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 and Analysis, Room 1014, Alexandria, VA 22302 ATTN:
PRA (0584-0484).

Name of Respondent: _________________________________ C/P/C_____/______/______
Purpose. You have been selected to participate in a research study being conducted by the United
States Department of Agriculture, Food and Nutrition Service and is authorized under 31 USC 3321,
The Improper Payments Information Act (IPIA) of 2002. The purpose of the study is to learn more
about the types of errors that occur when people apply for WIC benefits. We will be interviewing 2,400
randomly selected households from all over the United States.
Study Procedures. We have already contacted the staff at your local WIC agency. They, or the State
WIC agency, provided the names from which yours was randomly selected. They also allowed us to
review the file which was created when they determined your WIC eligibility. The interview will take
from 20-40 minutes. The interview will include questions about who lives in your home with you and
the income received by the household. Your responses to our questions will be entered into a laptop
computer and transmitted to study headquarters where the information will be processed.
Risks and Benefits. Participation is this study is strictly voluntary and will not result in any direct
penalty if you decide not to respond in the information collection as a whole or to any particular
question. The information you provide will be kept confidential and will not be disclosed to any one in
any identifiable form. The study findings will be used to make WIC program changes that will lead to
fewer errors when determining eligibility for benefits. Some of the questions are of a personal financial
nature and you may feel uncomfortable with some of them. You will be compensated $20 for your time.
Confidentiality. All information collected during this study will be kept confidential by the individual
field interviewers who conduct the surveys. The information is transferred onto secure computer
systems at study headquarters. The information you provide will not be shared with your WIC agency;
rather the data will be put together with that from other respondents and analyzed in groups and
subgroups. Your information will not be identified individually in any way.
Participant Rights. The United States Department of Agriculture and the federal Office of
Management and Budget have authorized this study to be carried out by Macro International. We look
forward to your participation. If you have any questions about this study, you may contact the study
director at Macro with this toll-free number:
800-xxx-xxxx
***********************************
Data Collector Certification. By signing this document, you are certifying that you read this
agreement to the respondent and that she/he [CHECK ONE] ____ agreed/____ disagreed to participate
in the National Survey of WIC Participants.
Data Collector Name [PRINT]: _____________________________
Data Collector Signature: ____________________________________ Date: __________________