Appendix G5 - Focus Group Participant Consent Form (Revised).

APPENDIX G5 -- Focus Group Participant Consent Form

T

OMB No. 0584-XXXX

Expiration Date: XX/XX/XXXX

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

Focus Group Participant Consent Form

The purpose of this study is to find out about your experiences with the Supplemental Nutrition Assistance Program or SNAP (formerly known as the Food Stamp Program). 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.

You were selected from a list of people provided by [STATE]’s SNAP office who began a SNAP application in the last several months, but were unsuccessful in qualifying for benefits. To better understand how this occurs, we are having discussion groups with people like yourself who were denied benefits during the application process. The benefit of participating in this focus group is it will help to improve the SNAP application process. Information about your experiences can help policymakers improve the program. You will be asked to share your experiences with different stages of the SNAP application process and what makes completing the application difficult. Throughout the focus group discussion, you do not have to answer any questions you do not want to. You may also stop participating at any time without any penalty. The session will last about an hour and a half. At the end of the discussion, we will give you $30 for your participation. This payment will not affect your potential eligibility for SNAP benefits in the future.

Participation in this study is voluntary. Deciding to participate or not to participate will not affect any benefits you are receiving or will be eligible to receive in the future. By participating in this focus group, 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, including recordings, will be kept in secured locations and identifying information will be destroyed as soon as they are no longer required. The only minimal risk which could arise from participation in the focus group is a breach of confidentiality. We ask that each participant respect each other’s privacy by not repeating any of the discussion they hear while participating in the focus group.

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 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 3 minutes 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.

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 Annalee Kelly at Mathematica Policy Research at (609) 275-2885. You will also receive a copy of this consent form for your records.

I have read this consent form and understand what I am being asked to do. By signing this consent form, I promise to keep what is discussed during the focus group, as well as keep the identities of all other participants, confidential.

Please print first and last name:

Signature:

Date:

Top Copy to Study Team, Bottom Copy to Participant