Various Demographic Area Pretesting Activities

Affordable Care Act Pretesting

Cognitive Interview Consent for Participation

Each year the Census Bureau conducts many different surveys. The Census Bureau routinely tests the questions used on these surveys in order to produce the best information possible.

You have volunteered to take part in a study to improve the questions that will be used in Census Bureau surveys that relate to health care coverage. In order to have a complete record of your comments, the cognitive interview will be audio taped. We plan to use the tapes to develop better questions for these surveys. Only staff directly involved in the research project will have access to the tapes. Your participation is voluntary and your answers will remain strictly confidential.

You will receive $40 in cash at the end of the interview to thank you for your participation.

This study is being conducted under the authority of Title 13 USC. The OMB control number for this study is 0607-0725. This valid approval number legally certifies this information collection.

I have volunteered to participate in this Census Bureau questionnaire design study. I also give permission to have this interview audio taped for the purposes stated above.

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Researcher's Signature Participant's Signature

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Researcher’s Name Participant’s Name

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