Supplemental Nutrition Assistance Program Employment & Training (SNAP E&T) Program Marketing/Outreach Support: Participant & Prospective Participant Discussions

OMB Control No. 0584-0611

Expiration Date: 11/30/2025

Attachment C: Consent Form

SNAP E&T Marketing Support Participant Focus Groups 

Consent Form

Note: Please note that this will be completed prior to the start of the discussions.

Informed Consent for Discussion

Thanks for taking the time to speak with us. Please read the statements below and sign where indicated.

By submitting this form you are indicating that you have read the description of the study and that you agree to the terms as described.

If you have any questions, or would like a copy of this consent form, please contact [email protected].

What this study is about

This discussion is part of a series of discussions conducted by the CMRignite on behalf of The United States Department of Agriculture Food and Nutrition Service (FNS) Supplemental Nutrition Assistance Program Employment & Training (SNAP E&T) Program. This is a project aiming to improve communications about the program to States, providers, and participants.

Your Involvement in the Study

We will ask you questions about your familiarity and/or experience with the SNAP E&T program and the information and resources it provides and information you may need about the program. With your permission, we will record you on audio and/or video, and we will take notes to document your comments. The activities should take a maximum of 80 minutes total.

Your Participation is Voluntary

Participation is completely voluntary. You may refuse to answer any questions or end participation at any time.

Confidentiality

We will take necessary and appropriate precautions to keep what you tell us confidential. We may develop and present summaries of the discussions for our team that include your anonymous comments and experiences shared. We will not use your real name in any of our materials.

Storage of Personal Information and Session Data

We will securely store and process your personal information and session data until we deem the content no longer necessary for the purposes outlined above. This data can include your name, email address, and phone number.

Statement of Consent

I have read the above information and received answers to any questions I have asked. I consent to take part in this discussion and to have any information I provide be used in the manner described above. I understand that my name will not be used in connection to my words or any recordings taken during the duration of the discussion. I expressly release Team LRG from and against any and all claims that I have or may have for invasion of privacy, defamation, or any other cause of action arising out of the production, distribution, display, or publication of the results of the project, so long as the conditions of use described above are met.

If you agree to participate in this study, please type your first and last name in the box below.

Please also type your initials here if you approve of and consent to having this conversation recorded, so that the small team working on this project can also benefit from your thoughts.

 

This information is being collected to assist the Food and Nutrition Service in enhancing the effectiveness of current communications efforts. This is a voluntary collection and FNS will use the information to improve communication and marketing efforts to. This collection does 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 0584-0611. The time required to complete this information collection is estimated to average 0.083 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, 5th Floor, Alexandria, VA 22306 ATTN: PRA (0584-0611). Do not return the completed form to this address.