D7_Informed Consent for Observation and WIC Participant Interview

Appendix D7. Informed Consent for Observation and WIC Participant Interview

OMB Control No: 0584-0663 Expiration Date: xx/xx/20xx Expiration Date: 03/31/2019

WIC Nutrition Assessment and Tailoring Study

Participant Informed Consent (with interview)

Background

Westat, along with our partners at Insight Policy Research, PHFE WIC, and Gabor & Associates, is carrying out the WIC Nutrition Assessment and Tailoring Study. This study is being done for the Food and Nutrition Service of the U.S. Department of Agriculture. About half the babies born in the U.S. are on WIC. This research study is being done to learn more about how WIC services can better meet the needs of people who receive WIC benefits. We are looking for about 500 people who receive WIC benefits to take part in our study. We would like you to help by allowing us to watch your visit today with WIC staff. We would also like to ask you some questions about your visit and your satisfaction with the WIC services you have received. If you do choose to take part in the study, we will give you $20 either in the form of a Visa gift card or by PayPal or Venmo following your talk with us as a thank you. We will also give you an extra $10 payment to cover the cost of minutes when using your own cell phone to complete the phone call. If you do not have a phone, we will provide you with a cell phone with enough pre-paid minutes to complete the phone call.

What Would I Do in the Study?

There are two things we would like you to do for this study:

1. Allow Us to Observe Your Visit Today

If you agree, we will observe your visit with WIC staff today. The observer will listen to your visit, and take notes. The notes will be about how the visit is conducted and the findings from your talk with WIC staff. None of the notes will in any way identify you or record the private information you discuss. If at any point you do not want the observer to listen, you can stop the visit and the observer will leave. You may choose to allow the observer to return later, if you like, but either way, you may still participate in the rest of the study.

2. Allow Us To Ask You Some Questions Following Your Visit

If you agree to take part in this study, we would also like to ask you some questions about your visit. If you have time today, we will ask the questions right after your WIC visit. Otherwise, we will agree to a time to talk with you on the phone. We will ask you about your WIC visit, how satisfied you are with the services you received, and any ideas you may have for improving WIC. The interview will take about thirty minutes.

What Are the Risks of Being In This Study?

We expect that your time in the study will be interesting and pleasant, and will not cause you any worry. However, there is a small risk to privacy if you choose to talk to us by phone after your visit, since you are giving us personal information. (You will need to give us your phone number and your name and address to mail the gift card or an email or username if you choose electronic payment like Venmo or PayPal.) We will take many steps to protect your privacy. Your name will not be used in any research reports. We will assign a study ID to your information, and we will not share information linked directly to you with WIC or with anyone else who is not on the study staff, unless otherwise required by law.

What Are the Benefits of Being In This Study?

There are no direct benefits to you for taking part in this study. The information collected during the study will help the Food and Nutrition Service understand better how WIC meets the nutrition needs of its participants. They will then use this information to continue to improve WIC services for everyone.

What Are My Rights As a Participant In the Study?

Taking part in this study is completely your choice. Giving consent means that you have heard or read the information about this study and that you agree to take part. You may still decide not to answer any questions that you do not want to answer. If you decide to take part in the study and then change your mind, you can stop at any time. There is no penalty if you stop taking part in the study, and it won’t affect any WIC services or other benefits you get.

Who Should I Call if I Have Questions?

If you have questions about the study itself and what we are doing, a member of our study team can help you. For those questions, please contact [NAME] at [XXX-XXX-XXXX].

If you have questions about your rights and welfare as a person who has agreed to take part in this study, please call the Westat Human Subjects Protections office at 1-888-920-7631. Please leave a message with your full name, the name of our research study (the WIC Nutrition Assessment and Tailoring Study), and a phone number with the area code. Someone will return your call as soon as possible.

Visit Observation Consent

1. By signing below, I am saying that I have heard or read the information presented here, and understand it. I agree to take part in the visit observation for the WIC Nutrition Assessment and Tailoring Study.

Signature

Date _______________

Interview Consent

2. By signing below, I am saying that I have heard or read the information presented here, and understand it. I agree to take part in the interview for the WIC Nutrition Assessment and Tailoring Study.

Signature

Date ___________

Interview Scheduling Information

Interview scheduled for:

Date _________

Time __________

Need Spanish-speaking interviewer: _____

If interview will be by phone:

Participant’s phone number: _____________________

Use participant’s cell phone: ____ Disposable phone provided: ____

Name and address for sending incentive payment by mail:

_____________________________________

_____________________________________

_____________________________________

_____________________________________

This information is being collected to assist the Food and Nutrition Service in obtaining a comprehensive and detailed description of the WIC nutrition risk assessment process and the ways in which participant benefits are tailored to address the assessment results. This is a voluntary collection and FNS will use the information to improve the delivery and tailoring of WIC services and increase satisfaction of both staff and participants. This collection does request personally identifiable information under the Privacy Act of 1974. 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 0584-0663. The time required to complete this information collection is estimated to average 5 minutes (0.08 hours) 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:  U.S. Department of Agriculture, Food and Nutrition Service, Office of Policy Support, 1320 Braddock Place, 5^th Floor, Alexandria, VA 22314 ATTN:  PRA (0584-0663). Do not return the completed form to this address.