SNAP work registrants and E&T program participants

Attachment 14: FOCUS GROUP participant consent form

ATTACHMENT A.14

FOCUS GROUP participant consent form

OMB Control Number: xxxx-xxxx; Expiration Date: xx/xx/xxxx

A TTACHMENT 14: FOCUS GROUP PARTICIPANT CONSENT FORM

SNAP EMPLOYMENT AND TRAINING STUDY

Focus Group Consent Form

Purpose. You have been selected to participate in a research study being conducted by the United States Department of Agriculture (USDA), Food and Nutrition Service (FNS). The USDA and the federal Office of Management and Budget have authorized this study to be carried out by Mathematica and Insight Policy Research. The purpose of the study is to learn more about employment and training services provided through the Supplemental Nutrition Assistance Program (SNAP), and how these services can better meet the needs of participants like you. We will be conducting 15 focus groups with SNAP employment and training participants across five States.

Study Procedures. Your state’s SNAP agency provided a list of SNAP recipients who are participating in a SNAP employment and training program. We selected your name from that list after looking at a number of characteristics such as age and gender. The focus group will take about 90 minutes. It will include questions about your employment history and goals, barriers to finding work, your training needs, and services you received through your employment and training program. Your responses to our questions will be recorded and sent to our research firm’s headquarters where the information will be processed. Your name will be removed from the information you provide so that no one can identify you with your answers.

Risks and Benefits. Participation in this study is strictly voluntary and will not affect your SNAP benefits in any way, even if you decide not to participate in the focus group or decide not to answer a particular question. The information you provide will be kept private and will not be disclosed to anyone in any identifiable form; except as otherwise required by law. The study findings will be used to help SNAP employment and training programs to better understand and serve their clients. Some of the questions are of a personal nature. As a token of appreciation, you will be given $40 after participating and can get an extra $10 incentive for showing up 15 minutes early.

Privacy. All information collected during this study will be kept private by the study team. The information is transferred onto secure computer systems at our research firm’s headquarters. The information you provide will not be shared with your SNAP agency; rather, the data will be put together with that from other respondents and analyzed in groups. Your information will not be identified individually in any way. If you have further questions, the FNS policy follows the System of Record FNS-8, FNS Studies and Reports, published in the Federal Register on April 25, 1991 at 56 FR 19078. It covers personal information collected under this study and identifies safeguards for the information collected.

Contact. We look forward to your participation. If you have any questions about this study, you may contact [NAME, TITLE] at [PHONE #].

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 focus group 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 <<xxxx-xxxx>>. The time required to complete this information collection is estimated to average 90 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.

DRAFT A14.1