Revised Consent Form

APPENDIX F
CONSENT FORM

The USDA National Food Study
Consent Form
Your consent is being sought to participate in the National Food Study. Your address was selected
at random using a scientific process to assure that all households have a chance to be selected. Please
read the following information carefully before you decide whether or not you consent to participate.
Sponsor of Study: The study is sponsored by the U.S. Department of Agriculture and conducted by
Mathematica Policy Research, an independent research firm.
Purpose of the study: This study will collect information to help USDA improve its programs and
help to assure that all Americans have access to a healthy diet at affordable prices.
Procedures to follow: If you agree to participate, we will ask you and members of your household to
keep track of the foods you get for 7 days. We will also ask you to complete interviews. The study
procedures include:
1. Complete three (3) 30-minute interviews:
a. Interview #1 will be done today, in person. It includes questions about your household,
where you shop for food, and whether you receive benefits from food assistance
programs.
b. Interview #2 will be done mid-week when a telephone interviewer calls you. It includes
questions about household income, assets, and major non-food expenditures.
c. Interview #3 will be done at the end of the week, in person. It includes general
questions about your family’s health, special dietary needs, nutrition knowledge, and
food security.
2. Receive a one-hour training to learn how to keep track of foods for the survey.
3. Save receipts from all of your household food purchases for the next 7 days.
4. Scan food items that you bring into your home during the next 7 days. We will give you a
scanner to use for the week. This may take about 20 minutes during the week.
5. Keep track of meals and snacks that you get away from home. This may take about 1 hour
during the week for each person age 11 and over who obtains food away from home.
6. Call us for three (3) 15-minute telephone calls to discuss the foods you get during the week.
It may take six to seven hours of your time during the week, depending on your household size.
Incentives/benefits for participation: This study provides three types of incentives:
 The primary food shopper in the household, who completes the three (3) interviews and
keeps track of food, will receive a $50 check at the end of the week after returning the
scanner and food books.


The primary food shopper will also receive up to three (3) $10 Walmart gift cards, one
for each time that you call us to report the foods you get during the week.



Other members of your family will receive a gift card if they keep track of the foods they
get: children age 11 to 14 will receive a $10 Walmart gift card and persons age 15 and older
will get a $20 Walmart gift card.

Duration or length of the study: You are being asked to participate for nine (9) days. This includes
today when you receive training and complete Interview #1, 7 days when you keep track of foods you
get, and a final day when we pick up your food booklets and scanner and conduct Interview #3.
Discomforts or risks: The risks are no greater than those ordinarily encountered in daily life. If you
receive Food Stamps, the study incentives will not affect your Food Stamp benefits.
Voluntary participation: 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 not, or withdrawing from the study, will not affect your eligibility for benefits or
services received by anyone in your household—now or in the future. Each household member may
decide to participate. Your household may participate even if all members do not agree to participate.
Termination of participation: You may choose to withdraw from the study at any time. You will not
receive the study incentives if you withdraw before the end of the 7 days for tracking foods you get.
Statement of confidentiality: We are required by law (read box below) to use your information for
statistical research only and to keep it confidential. The law prohibits us from giving anyone any
information that may identify you or your family without your consent.
Assurance of Confidentiality – All information which would permit identification of an individual, a
practice, or an establishment will be held confidential, will be used for statistical purposes only, will be
used only by ERS staff, contractors, and agents authorized by ERS to perform statistical activities only
when required and with necessary controls, and will not be disclosed or released to other persons
without the consent of the individual or establishment in accordance with section 308(d) of the
Public Health Service Act (42 USC 242m) and the Confidential Information Protection and Statistical
Efficiency Act (PL-107-347). By law, every employee as well as every agent has taken an oath and is
subject to a jail term of up to five years, a fine of up to $250,000, or both if he or she willfully
discloses ANY identifiable information about you.
We may obtain data from state agencies about your household’s participation in government food
programs, such as the Food Stamp program. Any data obtained this way will also be kept strictly
confidential and will be used ONLY for research purposes. Please initial below if you allow us to obtain
information from state agencies about your receipt of food program benefits. Your initials here are not
required for participation in the study.
Initial here:
Where to go with questions about the study: 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].
If you feel that you have been harmed in any way as a result of being in this study, or have questions
about your rights as a study participant, please contact: Margo Campbell at Public Private Ventures
Institutional Review Board, toll-free at 800-755-4778 extension 4446.
I read the information provided on this form. By printing my name and signing below, I show
that I am at least 18 years of age and I agree to take part in this study.
___________________________
Print Your Name

____________________________
Your Signature

_______ / ______ / 2011
Today’s Date