A 7 4 Consent Form_Group Residential Facility

OMB Control Number: 0584-XXXX
Expiration Date: XXXX

A.7.4 Consent Form: Group Residential Facility

You have been selected to participate in a research study being conducted by the United States Department of Agriculture, Food and Nutrition Service. The purpose of this study is to understand how NAP participants use cash benefits in food stores and the benefits and barriers to accepting the Family Card by retailers.

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

• Your participation is completely voluntary (not required), and will not affect the NAP benefits of any of your residents in any way nor will it affect your current procedures concerning the NAP benefits.

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

• All information collected during this study will be kept private and we will not share your organization name with anyone at USDA or the ADSEF office.

• With your permission, the discussion will be recorded. Since we are talking with a lot of people across Puerto Rico, this will help us keep track of and accurately report who said what. We will not share the recording with anyone from the NAP office, and we will destroy the recording when the study is over.

• Your input will help the program in charge of the Family Card to understand participants’ experiences, circumstances and needs with using their Family Card benefits and will help lawmakers make decisions about the Family Card program in the future.

• The information you provide will be kept private and your responses will not be identified individually in any way.

• You may choose to not answer any questions. You may also stop the interview at any time. You 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 the discussion.

• The discussion will last about 60 minutes.

Contact Information: The United States Department of Agriculture has authorized Insight Policy Research to conduct this study. If you have any concerns about your participation in this interview or have any questions about the study, please contact the study director Carole Trippe at Insight Policy Research at (586) 505-8949.

Certification: By signing this document, you are certifying that you have read this agreement and that you [CHECK ONE in each line]:

____ agree/____ disagree to participate in study

____ agree/____ disagree to have the interview recorded

Name [PRINT]: _________________________Signature:_____________________ Date: _____

According to the Paperwork Reduction Act of 1995, 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 valid OMB control number for this information collection is 0584-XXXX. The time required to complete this information collection is estimated to average 60 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.