Business or Other for Profit and Not-for-profit Respondents

OMB Number: 0584-XXXX

Expiration Date: XX/XX/XXXX

Appendix K.2. Concept Mapping Informed Consent Form

Thank you for your interest in participating in the U.S. Department of Agriculture’s Food and Nutrition Service (FNS) study of household food security and well-being in Puerto Rico. As a participating stakeholder, you will help the study team develop a conceptual map of Puerto Rico’s food system. The conceptual map is intended to describe points of resiliency and vulnerability in Puerto Rico’s food system and help policymakers improve the delivery and effectiveness of the Nutrition Assistance Program (NAP). Participating stakeholders will also help identify existing research gaps that should be filled to better address policies related to household food security and well-being. The results will be summarized and shared with FNS and may be seen by other policymakers, public health professionals, and researchers who work on food and nutrition assistance programs.

How you were selected

One or more members of a Technical Working Group recommended you based on your experience in one or more of the following areas: human services (e.g., food banks, community action agencies); public agencies (e.g., human services, education, healthcare); advocacy organizations (e.g., neighborhood associations, civic groups, faith communities); private businesses (e.g., agribusiness, food retailers); and academia (e.g., nutritionists, economists, political scientists). You are one of approximately 65 individuals who have been asked to participate in the concept map development.

Risks and privacy

There is little risk to participate in this study. You will not be asked for any personal information as part of this process. Should you choose to participate, you will be asked to respect the privacy of other group members by not disclosing any content discussed during the study. Researchers and data analysts from Insight Policy Research will combine participants’ responses and report them as overall findings, but your responses will remain private.

Benefits of the study

There are no direct benefits to you for participating in the study. However, the information you provide will help FNS make decisions that could strengthen food safety net and disaster relief programs in Puerto Rico.

Study costs and compensation

There is no cost to you to participate, apart from the time you will spend participating in the following tasks:

• Two 90-minute virtual meetings

• Review of background documents for each meeting (up to a 90-minute time commitment)

• An online assignment between the two meetings that will require approximately 60 minutes to complete

To thank you for your time, we will provide $50 honoraria after each virtual meeting ($100 total) (paid by check).

Voluntary participation

Your participation is entirely voluntary. Although we hope you will participate in both virtual meetings and all related activities, you may stop participating at any time without penalty.

Questions about the study

If you have questions or concerns about the study, please contact Ms. Danielle Hansen, the Insight Policy Research Project Manager, at [email protected] or 571.200.7936.

Consent to record virtual meetings

We will record the virtual meetings to help us fill any gaps in our notes and ensure we properly capture the discussion. The recordings, transcripts, and any notes we have will be stored on our secure server and will be destroyed after the project is complete.

[ ] I consent to being recorded

Name of Participant (printed): ______________________________

Signature: ______________________________________________ Date: ___/___/___

Please sign and return a copy of this informed consent form to Ms. Danielle Hansen at [email protected] at least 2 weeks prior to the first meeting. Keep the original, signed copy for your records.

Public Burden Statement

This information is being collected to assist the Food and Nutrition Service (FNS) in understanding food security status and economic well-being among Puerto Rico residents. This is a voluntary collection. FNS will use the information as a baseline for future assessments of food security and the Nutrition Assistance Program, particularly in the context of natural disasters. This collection does not 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-XXXX. The time required to complete this information collection is estimated to average 6 minutes per response, including the time for reviewing instructions 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, Alexandria, VA 22314. ATTN: PRA (0584-XXXX). Do not return the completed form to this address.

Food Security Status and Well-Being of NAP Participants in Puerto Rico, Appendix K.2. Concept Mapping Informed Consent Form K-2