A4 Consent Form_English Version

Appendix A-4

Consent

National Food Study Pilot

Agency: Economic Research Service

Contractor: Westat, Inc.

Consent Form

OMB Control Number: xxxx-xxxx

Expiration Date: xx/xx/xxxx

Your household is eligible to participate in the National Food Study (NFS) Pilot. Please read the following information carefully before you decide whether or not you consent to participate.

Sponsor of Study: The study is sponsored by the U.S. Department of Agriculture (USDA) under the authority of United States Code Title 7 Section 2026 (a) (1). The study is conducted by Westat, an independent research firm.

Purpose of the study: This study will collect information to help USDA improve its programs and help to assure that all residents of the US have access to a healthy diet at affordable prices.

Procedures to follow: Your household will be invited to complete the following activities:

1. Complete a 30-minute Initial Interview. This interview will be done with the primary respondent, the main food shopper or the meal planner in your home. It includes questions about household members and household’s grocery shopping events.

2. Receive a 45-minute training to learn how to keep track of foods for the survey. Members of your household age 11 and over are eligible to participate in the training.

3. Keep track of food and drinks purchased or obtained for free during the next 7 days. This includes scanning food items purchased or obtained for free and reporting food items obtained outside your home during the week. You will use your own smartphone, a smartphone that we provide to you, or a scanner connected to a computer to scan food items during the week. This may take each person about 25 minutes per day.

4. Save receipts from all of your household food purchases for the next 7 days.

5. Complete an individual Income worksheet online. This may take each person about 15 minutes.

6. Tell us which meals and snacks you have during the next 7 days. This may take each person about 3 minutes per day.

7. Complete a 30 minute Final interview: The interview will be done with the primary respondent at the end of the week. It includes questions about household income and household expenditures.

8. Complete a Respondent Feedback form. The form is to be completed by the primary respondent after the Final interview. This form will take 2 minutes to complete.

9. Complete a Recall Interview. The interview will be done with the primary respondent and one other member of your household. We will ask about the last two days you tracked food and drinks. This may take each person about 20 minutes.

10. If your household participates in the SNAP program, we would like your consent to access your administrative records to enhance the information you will be providing during this Study.

□ Please initial the box on the left if you agree.

Incentives for participation: The table below shows the incentives for a one-person household. If your household is larger, each additional person can earn money for completing the Food Log.

Initial Interview	Food Log	Income Worksheet	Final Interview + All Persons Complete Food Log	Recall Interview	Total
$50	$21	$5	$50	$50	$176

The table below displays the incentives and time to complete for different household sizes.

Number of Persons	Incentive Earned	Hours to Participate
1	$176	6.0
2	$197	10.6
3	$218	14.9
4	$239	19.2
5	$260	23.5
6	$281	27.8
7	$302	32.1
8	$323	36.3

Voluntary participation: Taking part in the study is voluntary. If you choose to participate, you can skip any question you do not want to answer or that makes you feel uncomfortable. Deciding to take part in the study or not, or withdrawing from the study, will not affect your eligibility for benefits or services received by anyone in your household—now or in the future. Each household member may decide to participate. Your household may participate even if some but not all members agree to participate.

Risks and Benefits: The risks are no greater than those ordinarily encountered in daily life. If you receive SNAP benefits (or food stamps), the study incentives will not affect your eligibility or benefit amount. There are no direct benefits to participating in this study.

Termination of participation: You may choose to withdraw from the study at any time. If you withdraw before you track foods for 7 days, you will receive only the study incentives for the period of your participation in the study. The study may use the data you provide to us up to the time of your withdrawal.

Statement of confidentiality: We are required by law (read box below) to use your information for statistical research only and to keep it confidential. The law prohibits us from giving anyone any information that may identify you or your family without your consent.

Assurance of Confidentiality: The Economic Research Service, its employees, agents, and partner statistical agencies, will use the information you provide for statistical purposes only and will hold the information in confidence to the full extent permitted by law. In accordance with the Confidential Information Protection and Statistical Efficiency Act of 2002 (Title 5 of Public Law 107-347) and other applicable Federal laws, your responses will not be disclosed in identifiable form without your informed consent. Per the Federal Cybersecurity Enhancement Act of 2015, Federal information systems are protected from malicious activities through cybersecurity screening of transmitted data.

If you have questions about this research, please contact Janice Machado, the Project Director at (301-294-2801; janicemachado@westat.com)

If you have questions about your rights and welfare as a research participant, please call the Westat Human Subjects Protections office at 1-888-920-7631. Please leave a message with your full name, mention that you are calling about the National Food Study, and leave a phone number beginning with the area code. Someone will return your call as soon as possible.

I read the information provided on this form. By printing my name and signing below, I show that I am at least 18 years of age and I agree to have my household take part in this study.

_____________________________	_____________________________	_______ / ______ / 20_____
Print Your Name	Your Signature	Today’s Date