SNAP Recipient Focus Groups (I/H)

APPENDIX F2: FARMERS’ MARKET FOCUS GROUP PARTICIPANT CONSENT FORM

Focus Group Participant Consent Form

OMB#: 0584-NEW

Expiration Date: xx/xx/20xx

Public reporting burden for this collection of information is estimated to average 90minutes per response, including the time for reviewing instructions, searching existing data sources, gathering and maintaining the data needed, and completing and reviewing the collection of information. 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, 3101 Park Center Drive, Room 1014, Alexandria, VA 22302 ATTN: PRA (0584-xxxx). Do not return the completed form to this address.

FOCUS GROUP CONSENT FORM

[Note: This will be read to participants and then they will be asked to sign it.]

Westat is a private company that does research for the government and private companies. We asked you in today to help us with a project that we are conducting on behalf of the USDA, Food and Nutrition Service. We will use your feedback to help us provide recommendations for improving these items.

We will be asking you to share your thoughts about shopping at farmers markets. Your participation in this research project is voluntary, and you have the right to leave at any time or to refuse to answer any question.

You will never be identified by name. The things you say today may be put into a written summary, but there will be no way to identify who said what, and your name will not be used anywhere. Participating in this study will not affect any of your benefits in any way at all. Also, it will not affect any benefits that you might receive in the future.

A notetaker will be present to take notes of the discussion and we will also record the discussion to help us summarize the important points. The recording will only be reviewed by a few Westat staff and possibly staff from the USDA Food and Nutrition Service. Only people working on this project will have access to the recording (it will be stored on a secure network drive) and notes and we will destroy the file when our project is finished. In addition, we will also destroy the electronic record of your responses and any identifying information when the project ends. Finally, a few people may be observing the focus group to help us understand and interpret some of the findings.

The session will take approximately 90 minutes.

You will be given $75 for completing the session.

If you agree to participate, please sign below.

I have read and understand the statements above. I consent to participate in this session.

____________________________________ _________________________________

Participant’s signature Date