Appendix A-9a Pretest consent form English_3_25_19

OMB Control No: 0584-0606

Expiration Date: 03/31/2019

Appendix A-9a: Pretesting Consent Form, English

You are being asked to take part in a research study conducted for the U.S. Department of Agriculture (USDA), Food and Nutrition Services (FNS). The study is to help us test questions that will be included in a survey about SNAP participation and work. Your input will help to identify ways to improve the survey.

The interview will last about an hour. You will receive $40 to offset any costs such as childcare or traveling that you may have incurred by your participation.

This is a research project and your participation is voluntary. If you prefer not to answer any of the questions just say so and we’ll move on. It’s also okay if you change your mind after starting and would rather not participate. However I can assure you that all of your answers, everything you say, will be kept private, and will not be shared with anyone outside the research team, except as otherwise required by law.

There are no known risks to you for taking part in this interview. Your name will not be linked to any of your responses, though we may include quotes you provide in our reports. Your information will be combined with information from other respondents and presented in summary form. If you decide not to participate in this interview, that decision will not affect any benefits or services you receive.

There are no direct benefits to you for taking part in this interview, but your answers will help us to develop recommendations for improving the survey questions.

Project staff from the Food and Nutrition Service and from [Westat/SPRA] may be observing this interview. They will hear your comments about the survey questions.

With your permission, I will audio-record the interview. This is done in case I missed something in my notes. The recording and all study materials that identify you will be destroyed by the end of the project.

If you have any questions about this study, please call [NAME] at [PHONE NUMBER].

If you have questions about your rights and welfare as a research participant, please call the Westat Human Subjects Protections office at 1-888-920-7631. Please leave a message with your full name, the name of the research study that you are calling about “Survey of SNAP and Work”, and a telephone number beginning with the area code. Someone will return your call as soon as possible.

I have read the information above and:

• I agree to participate in the interview.

• I agree to have my interview audio-recorded.

Signature: ___________________________________________ Date: _________

Print Name: __________________________________________

Name of Researcher: _______________________________

 

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Public reporting burden for this collection of information is estimated to average 2 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. An agency may not conduct or sponsor, and a person is not required to respond to, a collection of information unless it displays a currently valid OMB control number. 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 (0584-0606). Do not return the completed form to this address.