Appendix M Consent form for individuals-households in-depth interviews

Appendix M

Consent form for individuals/households in-depth interviews

EVALUATION OF CHILD SUPPORT COOPERATION REQUIREMENTS IN SNAP

Consent to Participate in Interview

By signing this form, you are agreeing to participate in an interview for a study that Mathematica is conducting for the U.S. Department of Agriculture Food and Nutrition Services. This study is examining a policy in some States that requires individuals with children to cooperate with the child support agency in order to keep the full amount of the assistance available to them through their participation in [NAME OF STATE SNAP PROGRAM]. [STATE] currently [HAS/DOES NOT HAVE] a child support cooperation requirement in [NAME OF STATE SNAP PROGRAM].

• [IN STATES WITH A CHILD SUPPORT COOPERATION REQUIREMENT IN SNAP]: As part of this study, we are talking to [PARENTS/CARETAKERS] like yourself to better understand your experiences with this requirement and what you think about those experiences, and about child support cooperation requirement more generally. You will also be asked to talk about any effects that you think the requirement has had on your participation in [NAME OF STATE SNAP PROGRAM] and in the child support program, or on the well-being of your family. This research will help the government better understand the effect of child support cooperation requirements on individuals and families. Your participation will help the government better understand the effect of child support cooperation requirements on individuals and families. There are no known risks to your participation.

• [IN STATES THAT ARE CONSIDERING HAVING A CHILD SUPPORT COOPERATION REQUIREMENT IN SNAP]: As part of this study, we are talking to [PARENT/CARETAKERS] like yourself to better a understand your experiences with [OBTAINING/PROVIDING] child support and your views about having a child support cooperation requirement in [NAME OF STATE SNAP PROGRAM]. You will also be asked to talk about any effects that you think this type of requirement would have on your participation in [NAME OF STATE SNAP PROGRAM] and in the child support program, or on the well-being of your family. Your participation will help the government better understand the types of issues and considerations this type of requirement raises for individuals and families. There are no known risks to your participation.

The interview will last approximately 90 minutes. It is your decision whether or not to participate in the study. If you choose to participate, you may stop at any time or refuse to answer any question in the interview without penalty. All of the information you provide will be kept private to the extent allowed by Federal law.

The information is being collected for research purposes only. After the research study is completed, the information you provide will be destroyed. Your name will never be used in any reports, and the information will never be reported in any way that can identify you. Nothing you say will affect your eligibility for the services and benefits you receive through any programs.

In appreciation for your participation in this interview, you will receive a $50 cash card. You will receive the cash card even if you decide not to answer certain questions.

Public 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-xxxx. The time required to complete this information collection is estimated to average 90 minutes 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 to XX; XX@YY.

If you have any questions, complaints, or concerns about this study, you may contact:

[NAME OF MATHEMATICA PROJECT DIRECTOR]

[PHONE]

[EMAIL]

I agree to take part in this interview. I have read the above interview description. Anything I did not understand was explained to me by the interviewer and my questions were answered to my satisfaction.

______________________________________________________________________

Participant Printed Name

______________________________________________________________________

Participant Signature Date

Privacy Act Statement

Authority: This information is being collected under the authority of Section 9 of the Food and Nutrition Act of 2008, as amended, (7 U.S.C. 2018). Disclosure of the information is voluntary.

Purpose: The information is being collected to evaluate Child Support Cooperation Requirements in United States Department of Agriculture (USDA) Supplemental Nutrition Assistance Program (SNAP).

Routine Use: The information may be shared with SNAP contract researchers and USDA SNAP research and administrative staff.

Disclosure: Disclosure of the information is voluntary. If all or any part of the information is not provided, interviews may not be admissible in data sets.

The Systems of Records Notices relevant to this collection are FNS-8 FNS Studies and Reports located at https://www.govinfo.gov/content/pkg/FR-1991-04-25/pdf/FR-1991-04-25.pdf and FNS-10 Persons Doing Business with the Food and Nutrition Service (FNS) located at https://www.federalregister.gov/documents/2000/03/31/00-8005/privacy-act-proposed-new-system-of-records.