HO-CHUNK NATION CONSENT FORM

Hello! Thank you for participating in our research study. The purpose of this consent form is to give you the information you will need to help you decide whether to be in the study or not. Please read the form carefully. You may ask questions about the purpose of the research, what I would ask you to do, the possible risks and benefits, your rights as a volunteer, and anything else about the research or this form that is not clear. When I have answered all your questions, you can decide if you want to be in the study or not. This process is called “informed consent.”

PURPOSE OF THE STUDY
The purpose of this study is to gather data on the food system of the Ho-Chunk Nation.  We will be gathering data on where tribal members purchase their food, how many tribal members are gardening or farming, and assess their level and knowledge of indigenous food preparation and cooking.


STUDY PROCEDURES
The survey should take about 15 minutes of your time. You may refuse to answer any questions at any time. 

All responses will be anonymous.

BENEFITS OF THE STUDY
By gathering information about the skills, needs and concerns of tribal members within the scope of Food. The information will be used by the HHCDA in their annual evaluation of the community gardening program.


CONFIDENTIALITY OF RESEARCH INFORMATION
Quotations may be used in published results, all responses will be anonymous.

OTHER INFORMATION
You may refuse to participate and you are free to withdraw from this study at any time without penalty or loss of benefits to which you are otherwise entitled.

If you have questions later about the research, you can ask one of the researchers or the HHCDA Garden program staff. If you have questions about your rights as a research subject, you can contact Garden Coordinator, Winona Mann at 608-374-1245 ext. 18830 or Winona.Mann@ho-chunk.com

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* 1. Are you a Tribal Member?

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* 2. What District do you live in?

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* 3. What is the size of your Household?

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* 4. Are there multiple families living in your household?

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* 5. How many tribal members are living in your household?

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* 6. How many non-tribal members are living in your household?

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* 7. What is your estimated annual household income?

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