Current, Former, and Recently Denied WIC Participants (Individuals/Households)

APPENDIX D9.a

PARTICIPANT CONSENT FORM – DENIED APPLICANT SURVEY - ENGLISH

Agreement to Take Part in the

U.S. Department of Agriculture – Food and Nutrition Service

Third National Survey of WIC Participants (NSWP-III)

Denied WIC Applicant Survey: WIC Applicant

You are invited to take part in an important study of participants in the Special Supplemental Nutrition Program for Women, Infants, and Children (WIC) program. The study is called the “Third National Survey of WIC Participants” (NSWP-III). The U.S. Department of Agriculture’s (USDA) Food and Nutrition Service (FNS) is funding the study. Abt Associates, Inc. and 2M Research Services, in partnership with Capital Consulting Corporation (collectively, “the research team”), are conducting the study for FNS. Your participation will help the research team and FNS to understand how well the WIC certification process is working.

Why you were invited to the study: The research team randomly selected individuals who recently applied for WIC and were told that they did not qualify for benefits at that time. Approximately 200 recently denied WIC applicants from across the U.S. were selected. [IF SAMPLED ADULT: You were one of those randomly selected.] [IF SAMPLED INFANT/CHILD: Your child was one of those randomly selected.]

Participation is voluntary: The research team encourages you to participate, but you are not required to take part in the study. Taking part in the study will not change the decision the WIC agency made about your application. However, if the answers you provide suggest that the local agency may have made a mistake, or if your circumstances have changed since you applied, you are always free to re-apply for WIC benefits at your local agency. The staff at your local WIC office do not know who was selected for the study. The research team will not tell your local WIC office whether you take part in the study.

What it means to participate in the study: If you agree to participate in the study, a trained interviewer from the research team will meet with you in person. The interviewer will ask for information about who lives with you, your family’s income and whether you receive SNAP (“food stamps”) TANF (“welfare” or “public assistance”), Medicaid or other public benefits. During the interview, the interviewer will ask to see certain documents. The interviewer will collect information from these documents and give them back to you. These documents may include a driver’s license or some other type of identification; [IF SAMPLED INFANT/CHILD: a birth certificate or letter from your child’s school or doctor;] a rental agreement or a utility bill or other mail that shows where you live; copies of paychecks, bank statements or other documents that show your income. If you receive SNAP (“food stamps”) TANF (“welfare” or “public assistance”), Medicaid or other public benefits, the interviewer may ask to see your program card or notice of benefits.

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 6 minutes (0.10 hours) 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-xxxx*). Do not return the completed form to this address.

During the interview, you can decline to answer any questions or provide any document the interviewer asks to see. If you do not have one or more of the documents, you can still take part in the study. You may stop the interview if you do not want to continue.

Privacy: The research team will use information about you or your family for research purposes only. Your responses to questions and the information you provide for this study are private to the full extent allowed by law. The research team will combine your information with information from other households. The research team will not share information that could identify you or anyone in your household with your local WIC office, FNS, or the USDA. Study reports will not identify you or anyone in your household. At the conclusion of the study, “anonymous” (non-identifiable) data from all study participants may be made available to other researchers interested in the study. These data will not include information that could identify you or anyone in your household. The information we collect will not be used to change your eligibility for WIC services or benefits, and you will continue to be free to apply for WIC benefits and services for which you are eligible. Your responses only will be used for summary tabulations and statements of best practices.

Study costs and compensation: There are no costs to you for participating in the study. As a token of appreciation, the interviewer will give you a $25 Visa debit card at the end of the interview. (If you re-apply for WIC in the future, you do not need to report this Visa debit card as income to your WIC office.)

Benefits and Risks of Participation: Your participation in this study may not benefit you directly. Your participation will help FNS learn if the WIC application process is working to ensure that WIC benefits reach those who need them most. The research team has strong precautions in place to protect your privacy, but there is a small risk of a breach of privacy. The research team will safeguard your privacy as follows: Only the interviewer and members of the research team will see your responses. Any papers that include personal information that identifies you or your family will be kept in a locked storage area and destroyed after the study ends. Any computer files with personal information that identifies you or your family will be protected by a password and stored on a secure network. In computer files we use to analyze data and prepare study reports, we will replace names and other identifying information with a code number. We will destroy computer files that contain names or other identifying information about you or your family after the study ends.

Questions: If you have any questions about this study, please contact [CONTACT NAME] at [CONTACT INFORMATION]. For questions or concerns about your rights as a study participant, please contact [IRB CONTACT NAME] at [IRB CONTACT INFORMATION].

Agreement to Participate

By signing this participation agreement, I confirm that I have read and understand the description of the FNS study. I have had the opportunity to ask my interviewer questions about the study. I understand that my participation in this study is voluntary. I understand that agreeing or declining to participate in the study will have no direct effect on my eligibility for the WIC program, and that taking part in the study will not change the decision the WIC agency made about my application. I understand that I am free to re-apply for WIC benefits at my local agency. I understand that I can refuse to answer any questions or end my participation in the study at any time without penalty. I understand that the research team will obtain information about me, as described above. I understand that the research team will protect my personal information to the extent provided by law, and that the research team will use the methods describe above to keep personal information about me private.

Participant name, signature and date:

________________________ _____________________ _____________

Name of Participant (Printed) Signature of Participant Date

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