Feasibility of Implementing SNAP in the Commonwealth of the Northern Mariana Islands (CNMI) - Business IC

OMB Control Number: 0584-0524

Expiration Date: 06/30/2016

Attachment C: NAP-Certified Retailer Consent Form

July 15, 2014

Commonwealth of the Northern Mariana Islands (CNMI) SNAP Feasibility Study

2014 NAP Retailer Interview Consent Form

You have been invited to participate in a one-hour interview with Insight Policy Research staff to answer questions about your business, how you process NAP coupons (also known as “food stamps”), and how you might be affected by some possible changes to the NAP program. This study is for the United States Department of Agriculture (USDA) to understand the impact of replacing the NAP program with the Supplemental Nutrition Assistance Program (SNAP).

If you agree to be interviewed, here are some things you should know:

• Your participation is completely voluntary (not required), and will not affect your NAP certification in any way.

• Your name and business name will never be used in any reports about this interview.

• With your permission, the interviewer will record the interview. The recording will help us put together your answers with everyone else’s when we write our report. We will not share the recording with anyone from the NAP office, and we will destroy the recording when the study is over.

• All information collected during this study will be kept private. We will not share your name with anyone at USDA or the NAP office.

• You will receive $20 for your participation when the interview is over.

• You may choose to not answer any questions. You may also stop the interview at any time. Your benefits will not be affected in any way if you stop the interview or decide not to answer a question.

• The interviewer will answer any questions you have about this interview before the interview begins. After the interview, we will give you a number you can call if you have other questions.

• The interview will last about one hour.

Contact Information: If you have any concerns about your participation in this interview or have any questions about the study, please contact Carla Bozzolo at Insight Policy Research at (571) 758-5036 or [email protected].

By signing this document, you are certifying that you have read this agreement and that you:

___ agree/___ disagree to participate in the study

___ agree/___ disagree to have the interview recorded

Name [PRINT]: ________________________________________________________________________________________ Signature: _________________________________________________________________ Date: _______________

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