CNPP MyPlate Focus Groups

OMB CONTROL NO.: 0584-0611

EXPIRATION DATE: 11/30/2025

Attachment C-1 Consent Form (English)

I, _________________________________________, agree to take part in this focus group.

I understand that I do not have to be in this study. I can leave at any time without penalty. I can agree to be in the study and then change my mind later.

I allow the United States Department of Agriculture (USDA) to use the information from this study. I understand that the information is for research only, and that my name will not be shared with anyone else. I understand that any results will be presented as an aggregate and my name will not be identified with any statements I made.

I agree to ask questions about the study if I don't understand something. If I have questions after the study is over, I can contact Glynis Donaldson at [email protected]. Those who complete the study will receive a $75 gift card as a token of appreciation.

Recording Release

I understand that I will be audio and video recorded during this study. I allow USDA to use the recordings of me for research purposes only. I understand that my name will not be used for any other purpose.

I give up any rights to the recording and understand the recording may be copied and used by USDA without my permission.

Summary

I have read and understood this consent form. I understand that I will get a copy of this form.

Print Name:         _________________________________________

Signature:           _________________________________________

Date:                   _________________________________________

OMB BURDEN STATEMENT: This information is being collected to assist the Food and Nutrition Service in understanding how best to communicate about one of its programs to the American public. This is a voluntary collection and FNS will use the information to increase awareness of one of its programs. 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 0584-0611. The time required to complete this information collection is estimated to average 0.05 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.