Consent Form

APPENDIX F
CONSENT FORM

Low Incentive Version

The USDA National Food Study
Consent Form
Your household has been selected randomly to represent others like you in the National Food Study
sponsored by the U.S. Department of Agriculture and conducted by Mathematica Policy Research. If
you agree to participate, we will ask you to help us collect data for seven days.
We will ask you to:
• Complete three interviews—two in person and one over the telephone
• Save receipts from your food purchases
• Scan food items that you bring into your home during the week
• Keep track of meals and snacks that you get away from home
• Complete three short telephone calls to discuss the foods you acquire during the week
In total, it will take about six to seven hours of your time during the week. After you finish, we will give
you $50. We will also give $20 to each additional member of your household (over age 5) who reports
the foods they get during the week. If you call us to complete three short telephone interviews about
the foods you get during the week you will get a $25 telephone bonus. A one-person household may get
$75 if they complete all survey activities; a four-person household may get up to $135 if they complete
all survey activities.
Taking part in the study is voluntary. If you choose to participate, you can skip any question you do
not want to answer or that makes you feel uncomfortable. Deciding to take part in the study, or
deciding not to, will not affect eligibility and any benefits or services received by anyone in your
household—now or in the future.
We are required by law to protect your privacy. We promise to keep your information confidential.
Academic and government researchers will use your information in combination with other data to
conduct national-level research that will help assure all Americans have access to healthy diets at
affordable prices. We may obtain data about your household’s participation in government food
programs, such as the SNAP program (formerly food stamps) from state agencies. Any data obtained
this way will also be kept strictly confidential and will be used ONLY for research and statistical
purposes. It is against the law for us to disclose or publish your name or address. All the people who
work on this study take an oath to protect the confidentiality of the information we collect.1
I read the information above and all my questions were answered. By printing my name and
signing below, I show that I agree to take part in this study.

___________________________
Print Your Name

____________________________
Your Signature

_______ / ______ / 2011
Today’s Date

If you have any questions about the study please call us at: 1-866-275-8659 or write to us at: National
Food Study, c/o Mathematica Policy Research, P.O. Box 2393, Princeton, NJ 08543-2393. The email
address is: [email protected].
1
In accordance with the Confidential Information Protection and Statistical Efficiency Act of 2002 (Title 5 of Public Law 107-347)
and other applicable federal laws, your responses will not be given out in identifiable form without your informed consent. Federal law
prohibits disclosure or release of your information for nonstatistical purposes. Persons who willfully and knowingly disclose your data to
unauthorized persons are guilty of a felony punishable by up to five years imprisonment and up to a $250,000 fine.

High Incentive Version

The USDA National Food Study
Consent Form
Your household has been selected randomly to represent others like you in the National Food Study
sponsored by the U.S. Department of Agriculture and conducted by Mathematica Policy Research. If
you agree to participate, we will ask you to help us collect data for seven days.
We will ask you to:
• Complete three interviews—two in person and one over the telephone
• Save receipts from your food purchases
• Scan food items that you bring into your home during the week
• Keep track of meals and snacks that you get away from home
• Complete three short telephone calls to discuss the foods you acquire during the week
In total, it will take about six to seven hours of your time during the week. After you finish, we will give
you $100. We will also give $25 to each additional member of your household (over age 5) who reports
the foods they get during the week. If you call us to complete three short telephone interviews about
the foods you get during the week you will get a $25 telephone bonus. A one-person household may get
$125 if they complete all survey activities; a four-person household may get up to $200 if they complete
all survey activities.
Taking part in the study is voluntary. If you choose to participate, you can skip any question you do
not want to answer or that makes you feel uncomfortable. Deciding to take part in the study, or
deciding not to, will not affect eligibility and any benefits or services received by anyone in your
household—now or in the future.
We are required by law to protect your privacy. We promise to keep your information confidential.
Academic and government researchers will use your information in combination with other data to
conduct national-level research that would help assure all Americans have access to healthy diets at
affordable prices. We may obtain data about your household’s participation in government food
programs, such as the SNAP program (formerly food stamps) from state agencies. Any data obtained
this way will also be kept strictly confidential and will be used ONLY for research and statistical
purposes. It is against the law for us to disclose or publish your name or address. All the people who
work on this study take an oath to protect the confidentiality of the information we collect.2
I read the information above and all my questions were answered. By printing my name and
signing below, I show that I agree to take part in this study.

___________________________
Print Your Name

____________________________
Your Signature

_______ / ______ / 2011
Today’s Date

If you have any questions about the study please call us at: 1-866-275-8659 or write to us at: National
Food Study, c/o Mathematica Policy Research, P.O. Box 2393, Princeton, NJ 08543-2393. The email
address is: [email protected].
2
In accordance with the Confidential Information Protection and Statistical Efficiency Act of 2002 (Title 5 of Public Law 107-347)
and other applicable federal laws, your responses will not be given out in identifiable form without your informed consent. Federal law
prohibits disclosure or release of your information for nonstatistical purposes. Persons who willfully and knowingly disclose your data to
unauthorized persons are guilty of a felony punishable by up to five years imprisonment and up to a $250,000 fine.