Disclosure Generic Exhibit B - Consent Form

Informed Consent
As part of a research study for the Consumer Financial Protection Bureau, ICF International is conducting
this in-depth one-on-one cognitive interview to learn more about how you make financial decisions.
Before you decide to participate in the interview, here are some things you should know:
•

Your participation is totally voluntary.

•

You can choose not to answer any questions you do not want to answer.

•

We will not disclose personal information about you, except as described in this form, unless legally
authorized or required by law to do so.

•

Your name will not be used in any written reports or presentations for this project.

•

We will take notes during the interview for our research purposes.

•

Staff from the Consumer Financial Protection Bureau and ICF International will observe the
interview from another room.

•

This interview will be audio and video recorded. The audio and video recordings may be shared with
the employees of the Consumer Financial Protection Bureau and authorized contractors who have a
need for the information for official business purposes. All such persons are under obligation to
protect the privacy of the information in the recordings.

•

You will receive a monetary stipend to compensate you for your time.

•

You may discontinue participation at any time, either by leaving the interview or not answering a
question, without penalty or loss of benefits.

•

Any questions you have about this interview and the study will be answered before we begin the
interview. Contact information is provided below for any questions that arise after your participation.

•

The interview will last approximately 60 minutes.

Contact information: If you have any questions or concerns about your participation in this interview or
our research study, please contact the Project Director, Michael Long, at 301-572-0945.
By signing this document you understand the above and agree to participate in this interview.
Print your name:

_________________________

Date:

_________________________

Signature:

_________________________

Witness: _________________________