D2a_EDECH final IDI consent form_2015.3.13

Evaluation of Demonstration Projects to End Childhood Hunger (EDECH)

ATTACHMENT D.2. PARTICIPANT INTERVIEW CONSENT FORM

[NAME OF STATE/ITO DEMO PROJECT] EVALUATION

Consent to Participate in Interview

By signing this form, you are agreeing to participate in an interview about [NAME OF STATE/ITO DEMO PROJECT]. The interview is part of a larger study being conducted by Mathematica Policy Research for the US Department of Agriculture Food and Nutrition Service to look at how programs designed to help families feed their children are working. We are talking to parents like you to better understand how families deal with a broad range of issues that relate to feeding their children and other family members while also making ends meet. The interviewer will ask you about your experiences purchasing and preparing meals, eating habits and behaviors, family size, circumstances that might make it difficult to access food, and your experience participating in nutrition assistance programs such as [NAME OF DEMONSTRATION PROJECT]. The interview 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 interview 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 information will never be reported in any way that can identify you. Nothing you say will affect your eligibility for the services and benefits you receive through any programs.

In appreciation for your participation in this interview, you will receive a $50 gift card. 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 interview. I have read the above interview description. Anything I did not understand was explained to me by the interviewer and my questions were answered to my satisfaction.

________________________________________________________________________

Participant Printed Name

________________________________________________________________________

Participant Signature Date

I have received a $50 gift card from the interviewer.

________________________________________________________________________

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.

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