FMCS OMB E3 Focus Group Consent form English

APPENDIX E3. Focus Group Consent Form -- English

OMB Number: 0584-0564

Expiration Date: 11/30/2014

Consent Form

Food and Nutrition Services (FNS) within the U.S. Department of Agriculture (USDA) is interested in increasing SNAP clients’ access to fresh fruits and vegetables. The focus group you will be participating in will help FNS understand some of the barriers to purchasing these healthy foods and ways in which they might be able to improve people’s ability to buy these items.

The information you provide in the focus group will be treated as confidential. You will not be identified by name in any of our reports. Your information will be combined with information from other participants in other groups and presented in summary form to FNS.

We will need about 60 minutes of your time. You will be paid $60 cash after the focus group.

The focus group will be audio-recorded and you may be observed by other researchers or staff at FNS.

Your participation in the discussion is voluntary and you have the right to stop at any time. You may also decline to answer any questions that we ask. Information collected during this focus group will be destroyed no later than 6 months after Westat’s contract with FNS has ended.

The researcher will be happy to answer any questions you have about the study.

If you agree to participate, please sign below.

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

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Participant's signature Date

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Participant's printed name

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Researcher's signature

According to the Paperwork Reduction Act of 1995, no persons are required to respond to a collection of information unless it displays a valid OMB control number. The valid OMB control number for this collection is 0584-0564. The time required to complete this information collection is estimated to average 90 minutes per response, including the time to review instructions, searching existing data resources, gather the data needed, and complete and review the information collected.

According to the Paperwork Reduction Act of 1995, no persons are required to respond to a collection of information unless it displays a valid OMB control number. The valid OMB control number for this collection is 0584-0564. The time required to complete this information collection is estimated to average 5 minutes per response, including the time to review instructions, searching existing data resources, gather the data needed, and complete and review the information collected.