DGA 2020-2025 Survey and Focus Group (English and Spanish)

OMB CONTROL NO.: 0584-0523

EXPIRATION DATE: 11/30/2022

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 0584-0523 and the expiration date is 11/30/2022. The time to complete this information collection is estimated at 2 minutes, including the time for reviewing instructions and completing the 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, Braddock Metro Center II, 1320 Braddock Place, Alexandria, VA 22314, ATTN: PRA (0584-0523). Do not return the completed form to this address.

Attachment A-4 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) Center for Nutrition Policy and Promotion (CNPP) to use the information from this study. I understand that the information is for purposes research only, and that my name will not be shared with anyone else outside this study, except as otherwise required by law. 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 Glynis Donaldson at [email protected] or at 703-842-0223.

Recording Release

I understand that I will be audio and video recorded during this study to help researchers keep track of detailed responses of participants during the focus group discussions. Audio and video recordings will be deleted 6 months after reporting. 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:                   ________________________________________

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