Evaluation of FY 2019 Summer Electronic Benefit Transfer (EBT) Demonstrations - Parents/Caregivers of Children (2 of 3)

Attachment F.1: Focus Group Sign-In Sheet

OMB Control No.: 0584-0524

Expiration Date: 12/31/2022

Thank you for helping us by being a part of this focus group. My colleagues and I are collecting information from individuals like you to evaluate the 2019-2022 Summer EBT Project for the Food and Nutrition Service of USDA. Your feedback will help FNS understand how the project has been implemented and how participating households – like yours – experience the project.

Our reports to FNS will describe the range of responses expressed by you and other parents/caregivers who contributed information, but we will not quote you or anyone by name.

We just have a few initial questions to ask you.

1. How many years have you lived in this community? (Please check only one)

O Less than 1 year

O 1 to 3 years

O 3 to 5 years

O More than 5 years

2. How many children in your household participate in Summer EBT? _____________________

3. What are the ages of your children who participate in Summer EBT? ___________________

If you have questions about the Summer EBT Evaluation, please contact:

U.S. Department of Agriculture

Food and Nutrition Services

Office of Policy Support

ATTN: Chanchalat Chanhatasilpa

PRA (0584-0524)

1320 Braddock Road

Alexandria, VA 22302

The Food and Nutrition Service (FNS) is conducting this study to obtain information about the experiences of the Summer Electronic Benefit Transfer (EBT) Project by grantees, retailers, school districts and participants. Participation in this study is voluntary and the information collected will be used to understand how Summer EBT projects are implemented in varying settings. This study does not collect personally identifiable information. Information collected in this study will be kept private to the full extent permitted by law. According to the Paperwork Reduction Act of 1995, an agency may not conduct or sponsor, and a person is not required to respond to, a collection of information unless it displays a valid OMB control number. The valid OMB control number for this information collection is 0584-0524. The time required to provide this information collection is estimated to average 3 minutes per response, including the time to review instructions, search existing data resources, gather and maintain the data needed, and complete and review the collection of information. Send comments regarding this burden estimate or any other aspect of this collection of information, including suggestions for reducing this burden, to: USDA/Food and Nutrition Service, Office of Policy Support, 1320 Braddock Place, 5th Floor, Alexandria, VA 22314 ATTN: PRA (0584-0524) .

For Official Use Only:

• Grantee:

• Date/Time