Appendix G Consent Form_03172021

Appendix G: Consent Form

I have read the information provided in Disclaimer and am voluntarily participating in this 8-day usability evaluation of the mobile app, FoodLogger. FoodLogger was developed by Westat, an independent research firm, and sponsored by the United States Department of Agriculture. I understand that, my interactions with the test administrators will be audio- and video-recorded, and my data entered into the FoodLogger will be saved. The recordings and other data will only be used to improve the product and will remain confidential. Only those who are directly involved in this study may have access to the recordings and other data. I give permission for my audio and video recordings, and other data to be used for the purposes stated above.

The OMB Control Number for this study is: 0536-0073 (Expiration Date: 05/31/2022). This valid approval number legally certifies this information collection.

Participant’s Name: ______________________________________

Participant's Signature: ____________________________________ Date: ­­­­­__________

Researcher’s Name: _____________________________________

Researcher's Signature: ___________________________________ Date: __________