Appendix D-3-Consent Form_Pretest 2

Appendix D-3: Adult Consent Form for Pretest 2

OMB Control Number: 0536-0073

Expiration Date: 01/31/2019

You are being asked to participate in the National Food Study. Please read the following information carefully before you decide whether or not you consent to participate.

Sponsor of Study: The study is sponsored by the U.S. Department of Agriculture (USDA) under the authority of United States Code Title 7 Section 2026 (a) (1). The study is conducted by Westat, an independent research firm.

Purpose of the study: This study will collect information to help USDA improve its programs and help to assure that all residents of the US have access to a healthy diet at affordable prices.

Procedures to follow: If you agree to participate, we will ask you and members of your household to keep track of the foods you get for 7 days. The study procedures include:

1. Complete a 12- minute screener. This interview will help us determine if your household is eligible to participate in the Study. If your household is eligible it will allow us to identify the main food shopper or the meal planner, who will serve as the primary respondent for the household. This interview will also collect information on smartphone ownership and internet access.

2. Complete a 30-minute Initial Interview. This interview will be done with the primary respondent before the seven-day data collection week starts. It includes questions about household members and household’s grocery shopping events.

3. Receive a 45-minute training to learn how to keep track of foods for the survey.

4. Keep track of food and drinks purchased or obtained for free during the next 7 days. This includes scanning food items that you bring into your home and reporting food items obtained and consumed outside your home. You will use your own smartphone, a smartphone that we provide to you, or a scanner that can be connected to a computer to scan food items during the week. This may take about 25 minutes per day during the week.

5. Save receipts from all of your household food purchases for the next 7 days.

6. Complete an individual Income worksheet online. This may take 15 minutes.

7. Keep track of meals and snacks that you get away from home. This may take about 3 minutes per day during the week for each person age 11 and over who obtains food away from home.

8. Complete a 30 minute Final interview: The interview will be done with the primary respondents at the end of the week. It includes questions about household income and household expenditures.

9. Complete a Respondent Feedback form. The form is to be completed by the primary respondent at the end of the data collection. This form will take 5 minutes to complete.

The average time that is required of each members in your household to participate in the study is 5 hours.

Incentives for participation: This study provides three types of incentives:

Your household will receive $50 if found to be eligible and for completing of the initial interview with the primary food shopper.

Your household will also receive $5 if all household members complete the income worksheet online.

Each household member (including the primary respondent) will receive $3 for every day that they either report food that they got or indicate that they did not get any food on a given day. Each household member can earn a maximum of $21 for recording food items.

Your household will receive a $50 bonus if all household members complete the required interviews, income worksheet, and record food items (or indicate that they did not get food) on all 7 seven days.

Voluntary participation: Taking part in the study is voluntary. If you choose to participate, you can skip any question you do not want to answer or that makes you feel uncomfortable. Deciding to take part in the study or not, or withdrawing from the study, will not affect your eligibility for benefits or services received by anyone in your household—now or in the future. Each household member may decide to participate. Your household may participate even if some but not all members agree to participate.

Discomforts or risks: The risks are no greater than those ordinarily encountered in daily life. If you receive SNAP benefits (or food stamps), the study incentives will not affect your eligibility or benefit amount.

Termination of participation: You may choose to withdraw from the study at any time. If you withdraw before you track foods for 7 days, you will not receive the study incentives. The study may use some of the data you provide to us up to the time of your withdrawal.

Statement of confidentiality: We are required by law (read box below) to use your information for statistical research only and to keep it confidential. The law prohibits us from giving anyone any information that may identify you or your family without your consent.

Assurance of Confidentiality: All information which would permit identification of an individual, a practice, or an establishment will be held confidential, will be used for statistical purposes only, will be used only by USDA staff, contractors, and agents authorized by USDA to perform statistical activities only when required and with necessary controls, and will not be disclosed or released to other persons without the consent of the individual or establishment in accordance with the Confidential Information Protection and Statistical Efficiency Act (PL-107-347). By law, every employee as well as every agent has taken an oath and is subject to a jail term of up to five years, a fine of up to $250,000, or both if he or she willfully discloses ANY identifiable information about you.

If you have questions about this research, please contact Janice Machado, the Project Director at (301-294-2801; [email protected])

If you have questions about your rights and welfare as a research participant, please call the Westat Human Subjects Protections office at 1-888-920-7631. Please leave a message with your full name, mention that you are calling about the National Food Study, and leave a phone number beginning with the area code. Someone will return your call as soon as possible.

I read the information provided on this form. By printing my name and signing below, I show that I am at least 18 years of age and I agree to take part in this study.

________________________	________________________	_______ / ______ / 2016
Print Your Name	Your Signature	Today’s Date

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