Private Sector- Business

OMB Control No: 0584-XXXX

Expiration Date: XX/XX/20XX

Appendix G. Informed Consent Form

OMB No. 0584-[NEW]

Assessing SNAP Participants’ Fitness for Work

Project Officer: Eric Sean Williams

Office of Policy Support

SNAP Research and Analysis Division

Food and Nutrition Service

U.S. Department of Agriculture

1320 Braddock Place

Alexandria, VA 22314

703.305.2640

[email protected]

Assessing SNAP Participants’ Fitness for Work

Informed Consent for Interviews of Staff

You are invited to participate in an interview for the Assessing SNAP Participants’ Fitness for Work study. This form will help you decide if you want to participate in the study.

Background

Researchers from two companies, MEF Associates and Mathematica, are conducting a study to learn more about States’ policies in assessing Supplemental Assistance Nutrition Program (SNAP) work requirements and participants’ physical or mental limitations that may make them unable to work. We are conducting this study on behalf of the Food and Nutrition Service (FNS) of the U.S. Department of Agriculture. 

While FNS provides general guidelines on fitness for work policies, there is much to learn about what States’ policies are, how these policies developed, and how States implement them. As part of this study, we are talking to State and local administrators, eligibility workers, and SNAP Employment & Training (E&T) staff in four States to learn about the development and implementation of policies and guidelines related to exempting participants from work requirements due to physical or mental limitations, as well as good cause determinations as they relate to participants’ ability to work. 

The purpose of the study is not to audit, but to help FNS learn more about States’ policies, the implementation of those policies, and the different approaches that States have taken to assessing whether SNAP participants are able to work or should be exempt from work requirements. 

What will I need to do?

This interview will take about [60-90] minutes. During our conversation, we’ll talk about topics related to the policies and implementation of determining whether applicants and participants should be exempt from work requirements due to physical or mental limitations.

What are the risks and benefits of participating in this interview?

There are no significant risks to your participation. Sometimes people feel uncomfortable answering some questions. If that happens, you do not have to answer them. Participating in the interview will not help you directly, but sharing your thoughts and experiences will provide more information on the policies and guidelines States use for determining whether individuals should be exempt from work requirements due to a physical or mental limitation.

Will you share information from the interview?

We will not share your responses with anyone outside the study team, which includes project staff from MEF, Mathematica, and FNS. We will keep your responses private to the extent permitted by law. We will take notes during the interview and will record the discussion if you give your permission. We will write a report for FNS about States’ policies related to exempting participants from work requirements due to physical or mental limitations and how States have developed and implemented these policies. The reports we write may list the names of the States that participated in these interviews, but we will not use your name or title or attribute any responses to you. However, because of the small number of States participating in the study, it is possible that a response could be correctly attributed to you.  

For a group interview, we ask that all participants keep what is said in this interview private. However, it is important to note that we cannot ensure that others who participate in this interview do not repeat what is said here.

Do I have to do the interview?

Your participation in this interview is strictly voluntary. There will be no penalties if you choose not to participate. You may choose to stop participating at any time and you may refuse to answer any question. 

Questions:

If you have questions about the study, you can call the project director, Mary Farrell at MEF Associates at 703-838-2723.

If you have questions or concerns about your rights as a study participant, you can contact Health Media Labs Institutional Review Board (IRB), a group that reviewed this study for your protection, at [phone number] or [email].

This information is being collected to assist the Food and Nutrition Service in understanding how States assess physical or mental limitations when screening for exemptions from work requirements or determining good cause. This is a voluntary collection and FNS will use the information to determine needs for technical assistance. This collection does not request any 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-[xxxx]. The time required to complete this information collection is estimated to average .0833 hours or 5 minutes per response, including the time for 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, 5th Floor, Alexandria, VA 22306 ATTN: PRA (0584-xxxx). Do not return the completed form to this address.

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