Attachment D-1 Consent Form (English)

OMB CONTROL NO.: 0584-0523

EXPIRATION DATE: 09/30/2019

Attachment D-1 Consent Form (English)

I, _________________________________________, agree to take part in this focus group.

I understand that I do not have to be in this study. I can leave at any time without penalty. I can agree to be in the study and then change my mind later.

I allow the United States Department of Agriculture (USDA) to use the information from this study. I understand that the information is for research only, and that my name will not be shared with anyone else. I understand that any results will be presented as an aggregate and my name will not be identified with any statements I made.

I agree to ask questions about the study if I don't understand something. If I have questions after the study is over, I can contact Margaret Carlson at [email protected] or at 703-842-0202.

Recording Release

I understand that I will be audio and video recorded during this study. I allow USDA to use the recordings of me for research purposes only. I understand that my name will not be used for any other purpose.

I give up any rights to the recording and understand the recording may be copied and used by USDA without my permission.

Summary

I have read and understood this consent form. I understand that I will get a copy of this form.

Print Name:         _________________________________________

Signature:           _________________________________________

Date:                   _________________________________________

OMB BURDEN STATEMENT: 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 0584-0524. The time required to complete this information collection is estimated at five 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. Send comments regarding this burden estimate or any other aspect of this collection of information, including suggestions for reducing this burden, to: U.S. Department of Agriculture, Food and Nutrition Services, Office of Policy Support, 3101 Park Center Drive, Room 1014, Alexandria, VA 22302, ATTN: PRA (0584-0523). Do not return the completed form to this address.