Parents-Minor Surveys

Appendix D2

Focus Group Participant Consent Form:

English

OMB#: 0584-XXXX

Expiration Date: xx/xx/20xx

Public reporting burden for this collection of information is estimated to average 90minutes 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. An agency may not conduct or sponsor, and a person is not required to respond to, a collection of information unless it displays a currently valid OMB control number. 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 Services, Office of Research and Analysis, 3101 Park Center Drive, Room 1014, Alexandria, VA 22302 ATTN: PRA (0584-xxxx). Do not return the completed form to this address.

FOCUS GROUP CONSENT FORM: ENGLISH

[Note: This will be read to participants and then they will be asked to sign it.]

Westat is a private company that does research for the government and private companies. We are working with another company, Abt Associates Inc. We asked you in today to help us with a project funded by the US Department of Agriculture, Food and Nutrition Service (FNS). We will use your feedback to help us provide recommendations for improving these services.

We will be asking you to share your thoughts about the Health Incentives Pilot (HIP). Your participation in this research project is voluntary, and you have the right to leave at any time or to refuse to answer any question.

Although there are no direct benefits to you for participating, the information you provide will help FNS improve HIP. There is little risk from participating in this focus group except for the very small risk of a breach of privacy and we have taken steps to make sure this does not happen. You will never be identified by name. The things you say today may be put into a written summary, but there will be no way to identify who said what, and your name will not be used anywhere. Participating in this study will not affect any of your benefits in any way at all. Also, it will not affect any benefits that you might receive in the future.

We would like to record this focus group. Sometimes it is helpful to review a portion of a tape as we write the summary. The recordings will be transcribed. If the recording or transcription is reviewed later, it will only be by a few Westat staff and possibly FNS. We will destroy the recording, the electronic record of your responses, and any information that identifies you 3 years after the project ends.

The session will take approximately 90 minutes.

You will be paid $75 in cash for completing the session.

If you have questions about the study, please contact Cindy Robbins at Westat at 800-937-8281 (toll-free).

If you have questions or complaints about you rights as a research participant, you should contact Teresa Doksum, Institutional Review Board Administrator at Abt Associates, at 877-520-6835 (toll-free).

If you agree to participate, please sign below.

I have read and understand the statements above. I consent to participate in this session.

____________________________________ _________________________________

Participant’s signature Date