Instruments

Informed Consent for CICPE Questionnaires

Purpose of the Study

The National Opinion Research Center (NORC) at the University of Chicago is conducting a study to better understand individuals’ attitudes toward government programs and determine what influences how much they participate in community activities. Questions will deal with media use, participation in community activities, and on-going advertisement campaigns. Your responses will help the government address individuals’ concerns, achieve better responses from the public, decrease burdens on the taxpayer, and distribute resources to the communities that most need them. This study is being funded by the Census Bureau.

You may find that some of the questions we are asking make you feel uncomfortable and you may choose not to answer any question for any reason. You may stop participating at any time, and there are no consequences if you choose to stop.

Risks and Benefits

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

Confidentiality

Federal law protects your privacy and keeps your answers confidential under Title 13 of the United States Code. Title 13, along with other strict U.S. privacy laws, require that we protect your information and maintain confidentiality. Any information with identifying characteristics will be kept in a secure location during the period of the study. Everyone who works on the study and comes into contact with sensitive data has completed Title 13 confidentiality training. They have also received Special Sworn Status with the Census Bureau and have signed an oath under the penalty of law that promises they will not divulge your confidential information.

Your answers will be used in statistical form only. Your personal identifying information such as your name, address and phone number are never publicly released and are only accessible to a limited number of trained and certified project staff. Survey findings are put into summary reports that contain no names or other personal information that could identify you.

Additional Information

If you have any questions about the purpose of this study, what the data will be used for or your participation, please contact project staff at XXX-XXX-XXXX.

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.