Appendix P.1 In-depth Interview Consent Form - English 1.17.17

APPENDIX P.1: IN-DEPTH INTERVIEW CONSENT FORM -- ENGLISH

OMB Number: XXXX-XXXX

Expiration Date: XX/XX/20XX

Food and Your Household Study In-depth Interview Consent Form

TITLE OF RESEARCH: Food and Your Household

SPONSOR: Food and Nutrition Services (FNS) of the United States Department of Agriculture (USDA)

WESTAT PROTOCL NO.: 6292.03.02

INVESTIGATOR NAME AND ADDRESS

Dr. Maeve Gearing

Westat

1600 Research Boulevard

Rockville, MD 20850

WHAT IS THIS RESEARCH STUDY ABOUT?

Westat and Insight Policy Research are conducting this study for the USDA. It will help the USDA understand barriers to healthy eating. We’d like to talk to you about why it may be hard to eat healthy foods on a tight budget. We want to know what influences the food you eat and the food you feed your family.

You are one of 120 people selected for this interview. We are interested in learning whether healthy eating is different in different parts of the country. For this reason, we are interviewing SNAP participants who live in different parts of the United States. We also want to know whether SNAP participants change how and what they eat during the benefit month. Therefore, we are interviewing some participants right after they get their benefits. We will interview some in the middle of the benefit months, and others at the end. We know that some people are more worried about having enough to eat than others. For this study, we have selected some people who are worried about having enough

food, and other people who feel they have enough food. We will compare what they say about the foods they eat and how they feed their families.

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 5 minutes per response, including the time for reviewing instructions, searching existing data resources, gathering and maintaining the data needed, and completing and reviewing the collection of information.

WHAT IS EXPECTED OF ME?

Please be available for the interview at the time we agreed on. Please be available for one and one-half hours. The interview will last no more than 90 minutes. We would like to ask you questions about the foods you eat and the food you feed your family

With your permission, we would like to record the interview. The recording will help us recall exactly what was said. This will improve our accuracy when we write our report. We store all recordings and any notes on the project team’s computers. They will be available to the project team only. We will destroy the recordings after the study is finished.

We would like to interview you in your home. We would like you to give us a “tour” of your kitchen and dining room. This tour will help us understand how you prepare food and what mealtimes at your household are like. If you have changed your mind about meeting in your home, please call us at 1-xxx-xxx-xxxx.

WHAT ARE MY RISKS?

You may feel uncomfortable sharing your experiences. If any questions that make you uncomfortable, you can tell us to skip them. Another risk is that others in your household may overhear you speaking to us.

WILL I GET PAID?

We will provide an incentive of $75 at the end of the interview to thank you for your time.

WILL I HAVE TO PAY?

No, you do not have to pay to participate.

CAN I PARTICIPATE IF I AM PREGNANT?

Yes, you may participate if you are pregnant.

WHO WILL SEE MY INFORMATION?

All information you provide will be kept private. Your name will not be used in any reports. No information that could identify you will be used in reports. We may use quotes from you or other participants in our reports, but no names will be linked to the quotes. We will not share any information about you with others outside of the study teams.

The only time we would need to break your confidentiality is if we heard that someone was hurting someone else or planning to hurt someone else. If this happens, by law we must call 911 or report it to the authorities.

VOLUNTARY PARTICIPATION AND WITHDRAWAL

Your participation in this interview is voluntary. There is no penalty if you decide not to participate. It will not have any effect on your SNAP benefits or any other benefits you get. You may end the interview at any time. You may skip any questions that make you uncomfortable.

CONCERNS OR COMPLAINTS REGARDING THIS STUDY Do you have questions about your rights and welfare as a research participant? If yes, please call the Westat Human Subjects’ Protection Office at 1-888-920-7631. Please leave a message with your full name and the name of the research study that you are calling about. The name of this research study is Food and Your Household Study. Please also leave your phone number beginning with the area code. Someone will return your call as soon as possible.

Please check the box if you agree to participate in the interview. Check the box if you agree to the audio recording. Please sign the form.

• I agree to participate in the interview.

• I agree to have my interview audio-recorded.

Signature: Date:

Print Name:

Signature of Interviewer: