Attachment F1 - Household Consent Form

Attachment F1. Household Consent Form and Disclaimer

National Food Study (NSF) Pilot Consent Form and Disclaimer

OMB Control Number: xxxx-xxxx

Expiration Date: xx/xx/xxxx

Your household has been selected to take part in the National Food Study (NFS) Pilot. Please read the following information carefully. Then, decide if you wish to take part.

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

Purpose of the Study. This study will gather information to help USDA improve food choices and food quality. It will also help make sure that all Americans can afford to get healthy food.

Procedures to Follow. Your family is invited to complete the following activities:

• Complete an Initial Interview with the main shopper or meal planner in your home, and a Training on how to use the Food Log.

• Complete a Training on how to use the Food Log if you are over 11 years or older.

• Complete an individual Profile questionnaire and tell us about all the Foods and Drinks obtained during the next 7 days. If you have children under 11 years old, we ask that you report for them. If your household chooses to use the study’s smartphone app. to tell us about your Food and Drinks, we will ask for your permission to track the locations you go to during your study week.

• Complete an Income Questionnaire if you are over age 15.

• Complete a Debriefing Interview with the main shopper or meal planner in your home.

Incentives and Time to Take Part: We will provide incentives to thank you for participating. The incentives and time to complete the study for a one-person household for each survey activity are in the table below¹. For each activity time includes minutes for reviewing instructions, electronic texts and communications, searching existing data sources, gathering and maintaining the data needed.

Task	Mail Screener	In-Person Screener	Initial Interview + Training	Food and Drinks	Debriefing Interview+Bonus	Income Questionnaire	Profile Questionnaire
Incentive	$5	$5	$40	$35	$16	$2	$2
Minutes	6	9	75	63	10	15	3

The incentives depend on the size of your household. A two-person home can receive a total of $144 for completing the study, while a four person home can receive a total of $222.

Voluntary Participation. Taking part in the study is voluntary. You can decide to take part or not. If you agree to take part, you can still choose not to answer certain questions. These decisions will not affect any current or future benefits or services that your family may receive. Your family may take part even if some but not all persons agree to take part.

Risks and Benefits. The risks are no greater than usual daily life risks. If you receive SNAP, WIC or other government benefits, they will not be affected by the study incentives you receive. There are no direct benefits to taking part in this study.

Termination of Participation. You may choose to stop taking part in the study at any time. If you stop taking part before the 7 days, you will get only the study incentives earned up to that point. The study may use the data you provide to us up to the time you decide to stop taking part.

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 USDA, 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.

Use of administrative data. We may obtain data from state agencies and other sources of administrative data about you or your household. Any data obtained this way will also be kept strictly confidential and will be used ONLY for research purposes. Do you allow us to obtain information from state agencies and other sources of administrative data? Your permission here is not required for participation in the study.

• Yes

• No

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 have read the information provided on this form. By providing an electronic signature and date I show that I am at least 18 years of age and I agree to have my household take part in this study.

1 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 displayed at the top of this form. The time required to complete this information collection is displayed in the table below and includes the time for reviewing instructions, searching existing data sources, gathering and maintaining the data needed, and completing and reviewing the collection of information.