P. Consent Form for Waiting Room Questionnaire Participants_final_clean_final response to PRAO

Appendix P. Consent Form for
Waiting Room Questionnaire Participants

OMB No. 0584-XXXX

Modernizing Channels of Communication
With SNAP Participants

March 2, 2020

Project Officer: Andrew Burns

Office of Policy Support

Food and Nutrition Service

U.S. Department of Agriculture

1320 Braddock Place

Alexandria, VA  22314

703.305.1091

[email protected]

Modernizing Channels of Communication With SNAP Participants:
Consent Form for Waiting Room Questionnaire Participants

PURPOSE: This form will be used to document each participant’s consent to participate in the waiting room interview.

You have been selected to participate in a research study being conducted by the U.S. Department of Agriculture’s (USDA) Food and Nutrition Service (FNS). The purpose of this study is to highlight best practices and lessons learned from various mobile communication strategies tested in State SNAP agencies through case studies.

If you agree to participate, here are some things you should know:

• Your participation is completely voluntary (not required) and will not affect your SNAP benefits in any way.

• Your name will never be used in any reports about this focus group.

• All information collected during this study will be kept private, and your responses will not be identified individually in any way; except as required by law.

• Your input will help FNS and States improve communication with clients and identify best practices that lead to improved program outcomes. This information is particularly important today because advances in mobile communications can help States streamline their operations while improving communication with SNAP participants.

• You may choose not to answer any questions. You may also leave the discussion at any time. You will not be affected in any way if you stop the discussion or decide not to answer a question.

• The interviewer will answer any questions you have about the discussion.

• The interview will take about 5 minutes. It will include questions about how you use or want to use your mobile device (smartphone or tablet) to perform SNAP-related activities.

• Two people will be randomly selected to receive one of two $10 [Visa/MasterCard/American Express/Discover] gift cards at the end of the day.

Contact Information: USDA/FNS has authorized Insight Policy Research to conduct this study. If you have any concerns about your participation in this discussion or have any questions about the study, please contact the Project Officer, Andrew Burns, at [email protected] or 703.305.1091.

Certification: By signing this document, you are certifying you have read this agreement. Please check the relevant box below to indicate whether you agree to participate.

I agree to participate in this study.

I do not wish to participate in this study.

Name [PRINT]:_________________________ Signature: _________________________ Date: ________

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 3 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. Send comments regarding this burden estimate or any other aspect of this collection of information, including suggestions for reducing this burden, to the following address: U.S. Department of Agriculture, Food and Nutrition Services, Office of Policy Support, , 1320 Braddock Place Alexandria, VA 2231, ATTN: PRA (0584-xxxx). Do not return the completed form to this address.