OOO.1_FG Consent

OMB Control Number: 0584-XXXX
Expiration date: XX/XX/XXXX

APPENDIX OOO.1:
FOCUS GROUP CONSENT FORM—ENGLISH

WIC Nutrition Education Study

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 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 90 minutes 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.

Agreement to Participate in Discussion Group

You have been asked to take part in a group discussion about the nutrition education you receive from the WIC program. By participating in the discussion, you will provide the WIC program with valuable information for a study of WIC nutrition education that is being conducted for the U.S. Department of Agriculture, Food and Nutrition Service (USDA FNS).

You are one of about 96 women who receive WIC benefits who will take part in discussion groups across the country. Your participation will take about 1½ hours.

There are no direct benefits to you from taking part in this discussion group. Your opinions will help the WIC program improve WIC nutrition education.

There are minimal psychological, social, or legal risks to taking part in this discussion group. We will not share your contact information with anyone outside the study team. All of your answers and the information you provide will be kept private. Your name will not be connected to your comments. Any materials with your name and contact information will be shredded at the end of the study.

Your participation is voluntary, and you do not have to take part in the discussion group. Even if you agree to participate now, you may stop participating AT ANY TIME or refuse to answer ANY QUESTION. Your decision on whether to participate will not affect your WIC benefits or eligibility.

We will take notes during the discussion, and the discussion will be tape recorded to capture the information shared in the group. After we conduct several of these group discussions, we will write a report for the USDA FNS; however, your name will not be associated with your responses in any reports. At the completion of this study, the audiotapes will be destroyed.

You will receive a $50 gift card at the end of the discussion group. The money you receive or your participation in the group will not in any way affect your WIC benefits.

If you have any questions about this group discussion, you may contact [Insert Name] through email [Insert Email] or by phone at [Insert Phone Number]. If you have any questions about your rights as a study participant, you may call RTI’s Office of Research Protection at 1-866-214-2043. If you have any questions about the discussion group, please call [NAME] at [phone number].

I agree to take part in this discussion group and to have the discussion recorded. I have read the information above. Anything I did not understand was explained to me by the group leader and my questions were answered.

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Participant’s Signature Date

OOO.1-1