Consent Form

APPENDIX G
CONSENT FORMS

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Form 1

The USDA National Food Study
Consent Form
You are being asked 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 (USDA) under the
authority of United States Code Title 7 Section 2026 (a) (1). The study is 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 residents of the US 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 one 30-minute interview and one 35 minute interview:
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 at the end of the week, in person. It includes questions
about household income, major non-food expenditures and financial practices like bill
paying. It also includes questions about your family’s health, special dietary needs,
nutrition knowledge, and food security. We will provide you with an Income
Worksheet to help you prepare for this interview.
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.
7. Complete a Respondent Feedback Form (4 questions) at the end of the week.
It may take four to six hours of your time during the week, depending on your household size.
Incentives for participation: This study provides three types of incentives:
 The primary respondent in the household, who completes the two (2) interviews and keeps
track of food, will receive a $100 check at the end of the week after returning the scanner
and food books.


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



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

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.
Discomforts or risks: The risks are no greater than those ordinarily encountered in daily life. If you
receive SNAP benefits (or food stamps), the study incentives will not affect your eligibility or benefit
amount.
Termination of participation: You may choose to withdraw from the study at any time. If you
withdraw before you track foods for 7 days, you will not receive the study incentives. The study may
use some of the data you provide to us up to the time of your withdrawal.
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 USDA staff, contractors, and agents authorized by USDA 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.
Use of administrative data: We may obtain data from state agencies about your household’s
participation in government food programs, such as the SNAP 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: Melissia Billarrial at Public Private Ventures
Institutional Review Board, toll-free at 800-755-4778 extension 4482.
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

_______ / ______ / 2012
Today’s Date