Consent Form

Attachment 5

Research Consent Form

Phase I and Phase II

Informed Consent

Thank you for your interest in helping us test some systems for a study we are conducting for the Bureau of Justice Statistics (BJS). BJS collects data on the amount of crime and victimization that is occurring in the US. BJS collects this information with a survey, called the National Crime Victimization Survey (NCVS). Westat is assisting BJS in redesigning the NCVS. We are testing an Interactive Voice Response system for the survey. IVR is a computer system that will ask you questions over the telephone and ask that you give your answers over the telephone.

Today we will ask you to go through the IVR version of this survey. The questions on the survey will ask about crimes that you may or may not have experienced. This is a research project and your participation is voluntary. You can skip any question and you can stop at any point. Everything covered today will be treated as confidential. Your name will never appear in survey data or any of the results described in the report.

The IVR survey will take about (10 minutes – PHASE I/30 minutes --- PHASE II)¹ to complete and we then would like to talk to you about your experience with this system. We expect the total amount of time this will take will not be more than 60 minutes. As a token of our appreciation, we have $40 cash for you.

If you have any questions about this study, you can call Pat Dean Brick, at 301-301-517-4196.

We would also like to audio record both your interaction with the computerized system and the conversation that follows. Do we have your permission to record?

Signature Date

1 The time used in the consent will depend on whether this is for Phase I or Phase II.