Various Demographic & Decennial Areas Pretesting Activities

NORC IRB Protocol Submission Form

STATEMENT OF INFORMED CONSENT

CICPE QUESTIONNAIRE TESTING

Purpose of the Study

The National Opinion Research Center (NORC) at the University of Chicago is working on some survey questions to be used in a national study of the public’s familiarity with government programs and how they learn about them and would appreciate your help in improving those questions. To help explore these potential items, the organization is conducting interviews to find out how clear the items are, how long they take to complete, and whether we have missed anything in the various topics we are interested in.

Study Sponsor

This study is funded by the United States Department of Commerce, Bureau of the Census.

Procedures

If you agree to participate in this interview, you will meet with an NORC interviewer for about one and a half hours. You will receive $40 for participating in the interview. This is a token of appreciation for contributing your time and knowledge to this study.

Risks and Benefits

While there is no direct benefit to you for participating in this survey, your responses will help the U.S. government better understand individuals’ attitudes toward the government programs and what influences how much they participate in community activities. Your feedback will help to make critical improvements to the survey questionnaires that will be used in this study. This information will help the government address individuals’ concerns, achieve better responses from the public, decrease the burden on the taxpayer, and distribute resources to the communities that most need them.

There are no known physical or psychological risks from taking part in this study. We will take all possible steps to protect your privacy.

Confidentiality

You will not be identified in any report of these interviews. Federal law protects your privacy and keeps your answers confidential under Title 13 of the United States Code. Any information with identifying information will be kept in a secure location during the period of the study. This information will be used solely for the purposes of this study and will be destroyed when the study is over.

Other Information

Your participation in this study is entirely voluntary. If at any point during the interview you wish to withdraw as a participant, please notify the interviewer.

If you have questions about your rights as a study participant, you may call Kathleen Parks, the NORC IRB Administrator, toll free, at 866-309-0542.

Recordings

We would like to audio record the interview discussion so there is an accurate record of comments made. The recording allows us to more carefully study the questions. If you agree, you may ask to stop the recording at any time, and we will turn off the machine. We will keep the recording in a locked room or in the safe keeping of a staff person. At a later time, staff from NORC who are on this project may listen to the interview. However, they will not know who you are. At the end of the project the recordings will be destroyed.

1. Do you have any questions?

2. Do you agree to allow us to record the interview?

If yes, turn on the tape recorder.

3. Will you please state your first name and repeat your consent to record the interview?

4. Have you understood the information that was presented to you?

5. Do you understand your right to withdraw as a participant at any time?

6. Do you choose to participate in the study?

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