Zero Income (I/H)

OMB Control Number: 0584-0524; Expiration Date: 4/30/2013

Attachment B1: Consent Form – English

Characteristics and Circumstances of Zero Income SNAP Households

2012 Interview Consent Form

Public reporting burden for this collection of information is estimated to average 5 minutes per response, including the time for reading text, asking questions and providing consent. 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 (0584-0524).

Purpose. You have been selected to participate in a research study being conducted by the United States Department of Agriculture, Food and Nutrition Service. The purpose of the study is to learn more about the strategies that people receiving Supplemental Nutrient Assistance Program (SNAP) benefits use to cope when they have no income. We will be interviewing 50 SNAP (formerly known as food stamp) participants who live in parts of DC, Maryland, Virginia and West Virginia.

Study Procedures. Your State SNAP agency provided a list of SNAP participants who reported no income when applying or re-applying for SNAP benefits. We selected your name from that list by chance. The interview will take about 1 hour. It will include questions about who lives with you and how you manage to get by. Your responses to our questions will be recorded and sent to study headquarters where the information will be processed. Your name will be removed from the information you provide so that no one can identify you with your answers.

Risks and Benefits. Participation is this study is strictly voluntary and will not affect your SNAP benefits in any way, even if you decide not to participate in the interview or decide not to answer any particular questions. The information you provide will be kept private and will not be disclosed to anyone in any identifiable form; except as otherwise required by law. The study findings will be used to help the SNAP program meet the needs of people like you. Some of the questions are of a personal financial nature. You will be given a $25 gift card as a token of our appreciation.

Privacy. All information collected during this study will be kept private by the individual field interviewers. The information is transferred onto secure computer systems at study headquarters. The information you provide will not be shared with your SNAP agency; rather the data will be put together with that from other respondents and analyzed in groups. Your information will not be identified individually in any way. If you have further questions, the FNS policy follows the System of Record FNS-8, FNS Studies and Reports, published in the Federal Register on 4/25/1991 at 56 FR 19078. It covers personal information collected under this study and identifies safeguards for the information collected.

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 Insight Policy Research. We look forward to your participation. If you have any questions about this study, you may contact the study director at Insight at 703-504-9480.

Certification. By signing this document, you are certifying that you have read this agreement and that you [CHECK ONE in each line]:

____ agree/____ disagree to participate in study

____ agree/____ disagree to have the interview recorded

Name [PRINT]: _____________________________Signature:_____________________ Date: _____