Attachment I2 - Household Equipment Form

Attachment I2. Household Equipment Form

Household PIN#_______________

N ational Food Study

Equipment Loan Form

The National Food Study is assigning you this equipment on loan. You and your household are responsible for taking reasonable care of it while it is in your possession. Please check below the type(s) of equipment you are borrowing for the purposes of participating in the National Food Study.

Equipment Loaned	Passwords/PIN
Laptop	_______________________________
Apple iPhone	[XXXX]
MiFi (Network Name: [NAME])	[XXXX]
Barcode Scanner	N/A

After verifying the information above is correct, please sign and date this form. Retain the form for your records. After signing this form, you will be responsible for taking reasonable care of the equipment. If the equipment is lost or stolen, or malfunctions in any way, please contact the National Food Study team immediately at 1-866-XXX-XXXX.

I understand that this equipment is property of the National Food Study. I agree to take reasonable care of the equipment referred to in this document and return it on the due date, _________________. I further understand that the equipment is only intended to be used for participating in the National Food Study and not for any personal use. SEE REVERSE SIDE FOR LOANER IPHONE GUIDELINES.

Instructions

Laptop: 1.) Turn on laptop 2.) Type password indicated above

The computer will take you directly to the National Food Study website.

Smartphone: 1) Turn on phone. 2.) To unlock phone, use the PIN: [XXXX]

Respondent Signature: _________________________________________________

Print Name:__________________________________ Date: __________________

Interviewer Signature: ___________________________

Date Returned: _________________________________

Study Loaner iPhone Guidelines

If you have been provided with a Westat iPhone for participation in the National Food Study, you must adhere to the following guidelines.

 

• The device is being provided exclusively for use on the National Food Study project. You and your household should not send, receive, or store personal messages, pictures, files, or other materials that you wish to keep “private”.

• Use of the device should be limited to participation on the study, and appropriate use of the device is expected. The device must not be used for accessing, transmitting, retrieving, or storing any information or communication (1) that is discriminatory or harassing or that may be perceived as derogatory to any individual or group, (2) that is defamatory or threatening, (3) that may be interpreted as hostile or offensive, or (4) for any other purpose that is illegal.

• You and your household should take care to keep the device secure and in working condition.

• You and your household should immediately report a misplaced, lost, or stolen device to the project. Include that Westat has installed the “Find My iPhone” app on the device in order to locate it in such an event but will not otherwise be using that function.

• The household incentive check will be issued once all Westat equipment has been returned to Westat.