F
OMB
Approval No.: 0584-XXXX
Approval
Expires: XX/XX/XXXX
Hello, my name is ___ from Mathematica. We recently sent you a letter describing a study we are conducting for the U.S. Department of Agriculture (USDA) to improve access in federal food assistance programs in your state.
As the letter states, we’d like to invite you to participate in a focus group discussion about how well [STATE’s] recent efforts are working. To do so, I just have a few questions to determine whether or not you are eligible for the study. If you are eligible, the focus group discussion will take about one hour at [LOCATION] and you will receive a $50 check as a thank you once the discussion is complete for participating in the group.
This gift will not affect any government assistance you may be receiving. Your participation is voluntary, but we hope you will choose to participate. All information we collect will be kept private, as required by law. There are no penalties if you decide not to participate.
To determine if you are eligible for the focus groups, I need to first ask you a few questions. This will only take a couple of minutes.
1a. First, are you currently receiving [WA: Basic Food Program,] SNAP or Food Stamp benefits?
YES 1 GO TO END
NO 0
DON’T KNOW d
REFUSED r
1b. Do you currently receive monthly Native American Food Commodities as part of the Food Distribution Program on Indian Reservations (FDPIR)?
YES 1 GO TO END
NO 0 GO TO 2
DON’T KNOW d GO TO 2
REFUSED r GO TO 2
END. Unfortunately you are not eligible for the focus group study. We appreciate your willingness to participate. Thank you.
2. (INTERVIEWER: ASK IF NOT OBVIOUS): What is your gender?
MALE 1
FEMALE 2
3. What is the highest grade or level of school you have completed or the highest degree you have received?
UP TO 12TH GRADE, NO DIPLOMA 1
HIGH SCHOOL GRADUATE 2
GED OR EQUIVALENT 3
SOME COLLEGE, NO DEGREE 4
ASSOCIATE’S DEGREE 5
BACHELOR’S DEGREE (EXAMPLE: BA, AB, BS, BBA) 6
MASTER’S DEGREE, PROFESSIONAL SCHOOL DEGREE, DOCTORAL DEGREE 7
DON’T KNOW d
REFUSED r
4. Are you of Hispanic or Latino origin?
Hispanic or latino 1
Not Hispanic or latino 0
DON’T KNOW d
REFUSED r
5. I am going to read a list of five race categories. Please choose one or more races that you consider yourself to be: American Indian or Alaska Native; Asian; Black or African American; Native Hawaiian or other Pacific Islander; White or some other race.
American Indian or Alaska Native 1
asian 2
Black or African American 3
Native Hawaiian or other Pacific Islander 4
WHITE 5
SOME OTHER RACE (SPECIFY) 99
________________________________(STRING (30))
DON’T KNOW d
REFUSED r
6. That’s all the questions we have. Based on your answers, we have selected you to participate in a focus group, which is scheduled for [fill date, time, and location]. Will you be available to attend this group?
YES 0
NO 1
If yes: As a token of appreciation, you will receive $50 for taking part in the focus group. Confirm participant contact information. Thank you for agreeing to help us out with these focus groups.
If no: I’m sorry that you will not be able to participate in the focus group. Thank you for your time.
According
to the Paperwork Reduction Act of 1995, no persons are required to
respond to a collection of information unless it displays a valid
OMB control number. The valid OMB control number for this
information collection is 0584-XXXX. The time required to complete
this information collection is estimated to average 5 minutes per
response, including the time to review instructions, search existing
data resources, gather the data needed, and complete and review the
information collection.
File Type | application/vnd.openxmlformats-officedocument.wordprocessingml.document |
File Title | MEMORANDUM |
Author | August Pitt |
File Modified | 0000-00-00 |
File Created | 2021-01-30 |