2010 AQE Focus Gro 2010 AQE Focus Group Respondent Consent Form

Consent to be a Participant in JBS/Aguirre International Focus Groups

JBS/Aguirre International is a research firm. We have a contract with the U.S. Census Bureau to learn ways to improve the US Census forms. The Census forms ask questions about such things as your age, gender, race, ethnicity and the number of people in your household. You can help us by being part of a focus group to share your views and ideas. The focus group will be led by a trained facilitator who will conduct a two-hour meeting with you and approximately 10 to 12 other participants.

The meeting will be videotaped and audio taped for later review and transcription so we can accurately report on the ideas and opinions shared by group members. Only the Census Bureau and JBS/Aguirre research staff will have access to the tapes. Within this framework, we will keep all of your answers confidential. Your name will never be included in any reports and none of your answers will be linked to you in any way. The information that you provide will be combined with information from everyone else participating in the study.

Your participation in the discussion group is voluntary. If you decide to participate, you can refuse to answer any question you do not wish to answer. Participation in this discussion group will involve some loss of privacy. We will ask for a name at the discussion group for identification purposes only and request that all participants use only first names during the group session. We will also ask you not to tell anyone outside the group what any particular person said in the group. However, we cannot guarantee that participants will keep the discussion private. All names will be kept confidential by our research staff.

Refreshments will be provided during the discussion group meeting. Additionally, you will receive $75 in cash for your participation at the close of the discussion group.

If you have any questions or concerns about participating in the discussion group, you can contact _________________________ at ____________________________

PARTICIPATION IN RESEARCH IS VOLUNTARY. You are free to decline to be in this study, or to withdraw from it at any point.

YOUR CONSENT

I have read this consent form. I have been given a chance to ask questions, and I feel that all of my questions have been answered. I know that am free to participate in the focus group or not. I am signing below to indicate that I agree to participate in this focus group and give permission for my responses to be video and audio-recorded.

_________________________________________ _________________________________________

Participant’s Name (Print) Participants email address

_____________________________________ ___ _________________________ ___________

Participant’s Signature Participants phone # Date

This study is being conducted under the authority of Title 13 USC. The OMB control number for this study is 0607-0952. This valid approval number legally certifies this information collection.

Attachment Q - JBS – Census Consent Form Final