Appendix I2 - Staff Interview Consent Form (New).

APPENDIX I2 -- Staff Interview Consent Form

OMB No. XXXX-XXXX

Expiration Date: XX/XX/XXXX

The Assessment of Contributions of an Interview to SNAP Eligibility and Benefit Determinations

Interview Consent Form

This study will assess the contributions of the eligibility interview when determining SNAP eligibility and benefit levels. The study will examine how eliminating the eligibility interview affects program outcomes, staff workload, and client satisfaction. Your state has been selected to participate in the study.

The study is being sponsored by the U.S. Department of Agriculture (USDA), Food and Nutrition Services (FNS), the federal agency that oversees SNAP. Mathematica Policy Research, an independent research company located in Princeton, New Jersey is conducting the study.

The study team has worked with state and county officials to identify the most appropriate sites and individuals to be interviewed, including staff from community-based organizations (CBOs). These interviews will help describe how the no-interview demonstrations operate relative to other operations and how they affect staff functions. You may be interviewed up to 2 times during the study.

The benefit of participating in this interview is it will help to improve understanding of how potential changes in SNAP eligibility interview requirements would affect both clients and staff. You will be asked to describe some of your general work experiences and any related the no-interview demonstrations, if applicable. Throughout the interview, you may choose to not answer any of the questions asked. You may also stop participating at any time without any penalty. The interview is expected to last between an hour and 90 minutes.

Your participation in this study is voluntary. Deciding to participate or not to participate will not affect your employment in any way. By participating in this interview, you are giving us consent to use the information collected today in the reporting of the results of this study. All individual information is confidential and will not be used in any way that could identify you. Responses will only be reported in larger groups and no information will be shared with anyone outside the team. All data collected will be kept in secured locations and identifying information will be destroyed as soon as they are no longer required. The only risk which could arise from participation in the interview is a breach of confidentiality.

This research has been approved by our Institutional Review Board, Public/Private Ventures (P/PV). For questions about your rights as a research participant, please contact Melissia Billarrial at P/PV at 1-800-755-4788, x4482. The call is free. For more information about this study, you can contact Scott Cody at Mathematica Policy Research at (617) 715-6937. For you records, a copy of this form will be provided to you.

I have read this consent form and understand that I am agreeing to participate in this study without any guarantee of the study’s results.

Please print first and last name:

Signature:

D

Public Burden Statement: An agency may not conduct or sponsor, and a person is not required to respond to, a collection of information unless it displays a valid OMB control number. The OMB control number for this project is XXXX-XXXX. Public reporting burden for this collection of information is estimated to be 100 minutes per response including the time for participating in the interviews and providing the extant data collection. 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: Rosemarie Downer

ate:

Top Copy to Study Team, Bottom Copy to Participant