Qualitative Research on Methods for Unduplicating People Suspected of Being Counted More Than Once During a Census

C onsent Form

For

Decennial Census Research

You have volunteered to take part in a study to improve questions that will be used in the next decennial census. In order to have a complete record of your comments, your interview session will be audio recorded. We plan to use the recordings to improve our questionnaires. Staff directly involved in the questionnaire design research project will have access to the recordings. Your participation is voluntary, and your answers will remain strictly confidential.

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

I have volunteered to participate in this Census Bureau questionnaire design study, and I give permission for my recording to be used 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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