Attachment D.6_Interview Consent Form 9-13-17

OMB Control Number: 0584-xxxx

Expiration Date: xx/xx/xxxx

Attachment D.6 Interview Consent Form

Evaluation of Alternatives to Improve Elderly Access to the Supplemental Nutrition Assistance Program (SNAP)

CONSENT TO PARTICIPATE IN INTERVIEWS

The United States Department of Agriculture, Food and Nutrition Service (FNS) runs the Supplemental Nutrition Assistance Program (SNAP). Under Section 17 of the Food and Nutrition Act, 2008 Social Policy Research Associates (SPR) has been contracted by FNS to conduct an evaluation of policies designed to help older individuals who are eligible for the program to receive benefits. Part of the research involves conducting interviews with people 60 years of age and older to learn about their experiences with the program.

By signing this consent form, you are agreeing to take part in this very important study. Your participation will help researchers understand the experiences of people 60 years of age and older who are eligible for SNAP. For this study, you will participate in one hour-long, recorded interview about your food purchasing habits, experiences with applying for SNAP, receiving benefits, and how the program may have, or have not, assisted you.

This study is voluntary and the decision to participate in the study is up to you. There are no penalties if you chose not to participate in part or in full. All information that is collected about you through the interview will be kept private and will be used for research purposes only. Your name will never be used in any reports and no information will be reported in any way that can identify you, except as otherwise required by law. You may also refuse to answer any questions asked of you.

I have read this consent form (or it has been read to me). I understand the information provided in these materials and voluntarily agree to participate. If I have questions I can call the evaluation Director, Melissa Mack, at 510-788-2478.

__________________________________________

NAME (Printed)

__________________________________________

SIGNATURE DATE

• I have received my thank you gift of a $20 Visa gift card.

Public reporting burden for this collection of information is estimated to average 6 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.  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 Policy Support, 3101 Park Center Drive, Room 1014, Alexandria, VA 22302 ATTN: PRA (0584-xxxx*).  Do not return the completed form to this address.