Census in Schools Focus Groups

Appendix B: CIS Focus Group Consent Form

Thank you for taking part in this important study for the Census Bureau. Our goal today is to gather information that will support the Census Bureau in shaping the Census in Schools program for the future and the 2020 Census. What you tell us today will help us better understand the needs of administrators and teachers to encourage their participation in the program and to help them convey the importance of the Census to children and their parents more effectively. The session will last 90 minutes.

As moderators and observers we conform to ICF Institutional Review Board requirements by protecting your confidentiality as you participate in this focus group. It is also important that each of you agrees to respect and protect each other’s privacy. By consenting to participate in this group, you agree to protect the confidentiality of all other group participants and to keep any information you hear today in strict confidence. This means you will not discuss anything you hear today with anyone outside of this group. Please be aware, however, that we cannot guarantee that other participants will uphold this pledge of confidentiality. If you are concerned about this risk, you should tell us if you would rather be interviewed individually, limit your participation in the group to what you are comfortable discussing, or not participate in the study at all.

We will take notes on what was said today. In the notes we produce after the end of the group, we will not link your name to anything you said. In our report to the Census Bureau, whenever we use a direct quote we will not reveal the source of the quote.

Your participation is voluntary. During the group discussion, you do not have to answer every question or discuss anything you do not wish to. You may stop participating at any time with no negative consequences. If you leave the session before the end you will still receive the $50. If you agree to participate, please print and sign your name below and write in the date.

Please note that we cannot conduct this focus group unless the protocol and the informed consent forms display valid OMB Control Numbers. Furthermore, you do not need to participate unless the protocols and forms have a valid OMB Control Number. The OMB Control Number is: 0607-XXXX. This collection expires September 30, 2011.

I have read and understand the information about this discussion group. I understand that I can stop participating in the group discussion at any time without penalty. I understand that, while confidentiality cannot be guaranteed, ICF will take steps to keep my responses private.

(Print) _____________________________________________________________________

First Name Middle Initial Last Name Date

(Signature) ____________________________________________________________________

OMB Control Number: 0607-XXXX 1

Expiration Date: September 30, 2011