Attachment F3 - Individual Assent Consent Form

Attachment F3. Individual Consent/Assent Form

Individual Assent/Consent Form

(This page will appear if a participant follows the link given in the Food Log)

OMB Control Number: xxxx-xxxx

Expiration Date: xx/xx/xxxx

Your household has agreed to participate in the National Food Study (NFS) Pilot. If you agree to take part, we ask that you complete the following activities:

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

• Complete an individual Profile Questionnaire.

• Tell us about all the Foods and Drinks obtained during the next 7 days. And, save all your hard copy receipts. If you choose 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.

• Use the training tab on the website or call the helpline if you need guidance with completing any form.

Incentives and Time to Take Part: The incentives you get for participating will be added to your family’s incentives. The incentives for completing each survey activity are in the table below¹.

Task	Training on Reporting Foods and Drinks	Reporting Foods and Drinks	Income Questionnaire	Profile Questionnaire
Incentive	$0	$35	$2	$2
Minutes	45 mins.	9 mins./ day	15 mins.	3 mins.

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 government benefits, 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 not to participate in the study at any time. If you withdraw before tracking 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 provided to us up to the time of 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 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.

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.

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.