consent form

Consent Form

Purpose: We are inviting you to participate in a research activity. The research involves individuals completing a survey and then answering questions about the experience of completing it. The feedback will help us to develop recommendations for improving the survey.

Sponsorship: Westat is conducting this project on behalf of, and funded by, the Bureau of Justice Statistics (BJS).

What is involved: We will be asking you to complete a paper survey and then answer questions about it. We will also ask for your feedback on the other mailed materials, including an envelope and a cover letter. Your participation in this research project is voluntary, and you have the right to stop at any time or to refuse to answer any question. The session will take approximately 60-90 minutes.

Confidentiality: We would like to record the interview. Sometimes it is helpful to review a portion of a recording as we make recommendations for improving the survey. If the recording is reviewed later, it will only be by a few Westat staff and possibly the client.

You will never be identified by name. The things you say may be put in a written summary of this discussion, but there will be no way to identify who said what, and your name will not be used anywhere. The information you provide will be used for statistical purposes only and may not be disclosed, or used, in identifiable form for any other purpose as required by law (Title 42, U.S. Code, Sections 3789g).

Risks: The only cost to you is the time and effort to answer questions. You may skip any question that you do not want to answer, both in the questionnaire and in the discussion afterwards. The information you provide will be treated as confidential. The recordings will be destroyed within 3 months of the end of the study.

Benefits: There are no direct benefits to you for participating in this study. However, you will be helping with an important research project.

Questions: If you have questions about the project, you may call the Task Manager, Pat Dean Brick, at 800-937-8281, Ext. 4196. If you have questions about your rights and welfare as a research participant, please call the Westat Human Subjects Protections office at 1-888-920-7631. Please leave a message with your full name, the name of the research study that you are calling about, and a phone number beginning with the area code. Someone will return your call as soon as possible

You will be paid $40 cash for completing the session.

If you agree to participate, please sign below.

I have read and understand the statements above. I consent to participate in this session.

Participant’s signature Date