Appendix G. Informed Consent Script

OMB Approval No. 0584-####

Expiration Date: XX/XX/XX

Appendix G. Informed Consent Script

This information is being collected to assist the Food and Nutrition Service (FNS) in understanding Supplemental Nutrition Assistance Program (SNAP) and Medicaid coordination. This is a voluntary collection and FNS will use the information to aid in the administration of SNAP. 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-[xxxx]. The time required to complete this information collection is estimated to average 5 minutes (.0833 hours) per response, including responding to recruitment outreach, participating in interviews, and reviewing and providing feedback on process maps. 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 any completed materials to this address.

Introduction and Consent

My name is ____ and I am a researcher at _____ (MEF Associates or the State Health Access Data Assistance Center – SHADAC). We are conducting a study on behalf of the Food and Nutrition Service (FNS) of the U.S. Department of Agriculture to learn more about current and planned coordination between the Supplemental Nutrition Assistance Program (SNAP) and Medicaid in State agencies. The study seeks to better understand State agencies’ approaches to coordinating policies, processes, and/or systems for SNAP populations and the populations in Medicaid whose income eligibility is based on Modified Adjusted Gross Income (MAGI) and the results of coordination practices.

My colleagues and I are talking with State and local administrators, frontline staff, IT staff, and community-based providers in five States to learn about how and why States coordinate their SNAP and MAGI-Medicaid programs, including any barriers and facilitators to coordination and highlighting promising practices. We recognize that your State may also coordinate with other programs, such as TANF, however we are only focusing on SNAP and MAGI-Medicaid programs for this study. If time permits and you have promising practices to share related to coordinating SNAP and non-MAGI Medicaid programs, we’d like to hear about those too. The purpose of this study is not to audit or identify actions that may be correct or incorrect, but to help FNS learn more about States’ approaches to coordination to improve efficiency, customer service, accuracy, and program access. In addition, we hope to identify and share best practices that can guide you and other State agencies in their effort to coordinate SNAP and Medicaid.

There are no significant risks to your participation in this study. 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.

We will take notes over the course of the interview and would like to audio record the conversation to help us remember the information we collected. We will keep your response private to the extent permitted by law. For example, we are obligated to report if an interviewee reports hurting themselves or others. We will not share your responses with anyone outside of the study team, which includes project staff from MEF, SHADAC, and FNS. The information you share with us today will be summarized and combined with information gathered from other people we interview. 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.

[IF A GROUP INTERVIEW] We cannot guarantee that everyone in this room, other than the study team, will maintain your privacy. However, we ask that no one repeats any of the information shared during this conversation today.

We estimate that our discussion will take [60-90] minutes.

Before we continue, do you have any questions about the project or about the subject of this interview?

Do I have your permission to record this interview?

USDA is an equal opportunity provider, employer, and lender.