D1a_EDECH final FG consent form 2015.3.13

OMB Control No: 0584-XXXX

Expiration date: XX/XX/XXXX

Evaluation of Demonstration Projects to End Childhood Hunger (EDECH)

ATTACHMENT D.1.a. PARTICIPANT FOCUS GROUP CONSENT FORM

[NAME OF STATE/ITO DEMO PROJECT] EVALUATION

Consent to Participate in Focus Group

By signing this form, you are agreeing to participate in a group discussion about [NAME OF STATE/ITO DEMO PROJECT] and to complete a short form to provide a description of your background. The discussion is part of a larger study being conducted by Mathematica Policy Research and Gabor Associates for the US Department of Agriculture Food and Nutrition Service to look at how efforts designed to help families feed their children are working. The group will discuss what you think is working well in [NAME OF STATE/ITO DEMO PROJECT], what you think could be improved, and how this effort may be helping you and your children. The group discussion will last approximately 90 minutes.

It is your decision whether or not to participate in the study. If you choose to participate, you may stop at any time or refuse to answer any question in the discussion or on the background form, without penalty.

All of the information you provide will be kept private to the extent allowed by federal law.

The information is being collected for research purposes only. After the research study is completed, the information you provide will be destroyed. Your name will never be used in any reports and no information will be reported in any way that can identify you. Nothing you say will affect your eligibility for the services you receive through any programs.

In appreciation for your participation in this group discussion, you will receive a $50 gift card to [NAME OF STORE]. You will receive the gift card even if you decide not to answer certain questions.

If you have any questions, complaints, or concerns about the study, you may contact:

[NAME]

[PHONE]

[EMAIL]

I agree to take part in this discussion group. I have read the above group discussion description. Anything I did not understand was explained to me by the focus group leader and my questions were answered to my satisfaction.

________________________________________________________________________

Participant Printed Name

________________________________________________________________________

Participant Signature Date

I have received a $50 gift card from the group leader.

________________________________________________________________________

Participant Printed Name

________________________________________________________________________

Participant 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 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.