Consumer Response Intake Form Improvement Study

CFPB’s Consumer Response Intake Form Improvement
Study (OMB Control Number: 3170-0042)

Web-Based Screener
Thank you for your interest in participating in user experience studies at Fors Marsh Group. We are
seeking participants to complete tasks and provide feedback on a website. One-on-one interviews
will be held [Insert dates] and will take place at our office in Arlington, VA. If you are interested in
participating, please complete this questionnaire. If you qualify for this study, we will contact you for
further screening and to schedule you at a time that is convenient for you. Compensation ($75) will
be provided to those who participate in the study.
Paperwork Reduction Act Statement [Link to new window].
[Paragraph below in the new window]
Paperwork Reduction Act
According to the Paperwork Reduction Act of 1995, an agency may not conduct or sponsor,
and a person is not required to respond to a collection of information unless it displays a
valid OMB control number. The OMB control number for this collection is 3170-0042. It
expires on 5/31/2015. The time required to complete this information collection is
estimated to average approximately 3 minutes per response, including the time for reviewing
any instructions, searching existing data sources, gathering and maintaining the data
needed, and completing and reviewing the collection of information. Responding to this
collection of information is voluntary. Comments regarding this collection of information,
including the estimated response time, suggestions for improving the usefulness of the
information, or suggestions for reducing the burden to respond to this collection should be
submitted to Bureau at the Consumer Financial Protection Bureau (Attention: PRA Office),
1700 G Street NW, Washington, DC 20552, or by email to [email protected].
Privacy Act Statement:
5 U.S.C. 552(a)(e)(3)
The information you provide through your responses to Fors Marsh will assist the study
sponsor, the Consumer Financial Protection Bureau (“CFPB”) in evaluating the most efficient
and effective website design.
The CFPB will not obtain or access any directly identifying information about study
participants. The agency will only obtain and access de-identified results and aggregated
analysis of those results.
Information collected on behalf of the CFPB will be treated in accordance with the System of
Records Notice (“SORN”), CFPB.021 – CFPB Consumer Education and Engagement Records,
77 F.R. 60382. This information will not be disclosed as outlined in the Routine Uses for the
SORN. Direct identifying information will only be used be to facilitate the study and will be
kept private except as required by law.

This collection of information is authorized by Pub. L. No. 111-203, Title X, Sections 1013
and 1022, codified at 12 U.S.C. §§ 5493 and 5512.
Participation in this study is voluntary, you are not required to provide any identifying
information, and you may withdraw participation at any time. However, if you do not include
the requested information, you may not be able to participate in the study.

Thank you for your interest.
Q1.

First name: [Text box]

Last name: [Text box]

Q2.

Email [Text box]

Q3.

Mobile number: [Text box]

Q4.

Alternate number: [Text box]

Q5.

What is your age?
1. 18-25
2. 26-35
3. 36-45
4. 46-55
5. 56-65
6. Over 65

Q6.

What is your gender?

1. Male
2. Female
Q7. Do you consider yourself Spanish/Hispanic/Latino?
1. No, not Spanish/Hispanic/Latino
2. Yes, Spanish/Hispanic/Latino
Q8.

How do you describe your race?
1. American Indian or Alaska Native
2. Asian
3. Black or African-American
4. Native Hawaiian or other Pacific Islander
5. White

Q9.

What city and state do you live in? [Text box]
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Q8.
In the past year, have you had any issues with the following financial products and services?
[Check boxes, select all that apply]
1. Credit card
2. Prepaid card
3. Government benefit card or payroll card
4. Mortgage
5. Student loan
6. Vehicle loan or lease
7. Payday loan
8. Debt collection
9. Credit reporting
10. Checking or savings account
11. Other: Please specify [Text box]
12. I haven’t had any issues with financial products or services
Q9.
[If Q8_1 - Q8_5 is selected] Tell us a little about the issue(s) you had (1 or 2 sentences,
please).
Q10.

What is the highest educational degree that you have earned? [Radio buttons, select only
one]
1. Less than high school degree or equivalent
2. High school graduate (grade 12, diploma, or GED)
3. Trade school certificate
4. Some college courses completed
5. Graduated with a 2 year degree (Associates)
6. Graduated with a 4 year degree (Bachelors)
7. Some graduate school courses completed
8. Graduated with a post-graduate degree

Q11.

Which of the following best describes what you are currently doing? [Check boxes, select all
that apply]
1. Going to high school
2. Going to community college, 2-year degree program, or trade school (either full-time or
part-time)
3. Going to a 4-year college/university (either full-time or part-time)
4. Working full-time
5. Working part-time
6. Homemaker
7. Retired
8. Not employed

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Q12.

What is your annual household income? [Radio buttons, select only one]
1. Less than $30K
2. $30K - $50K
3. $50K - $100K
4. $100 - $150K
5. More than $150K

Q13.

How did you hear about research opportunities with us?
1.
2.
3.
4.
5.
6.
7.
8.
9.

Google
Facebook
Washington Post online
Washington Post paper
Express newspaper
Craigslist.org
Restaurants or Cafes (e.g., Starbucks, Panera, Buzz Bakery)
Friend or Family Other [Text box]

This study is taking place [Insert dates]. Please enter three days and times that will be the most
convenient for you to come to our office to participate. Expect to be in our office for a little longer
than 60 minutes.
1. Date [Text box] Time [Text box]
2. Date [Text box] Time [Text box]
3. Date [Text box] Time [Text box]
Thank you for completing this survey. We hope to be in contact with you soon about scheduling a
time for you to participate. If you have any questions please contact us at [email protected]
or call us at 571-858-3776. You can also visit our website at www.forsmarshgroup.com or our
Facebook page: http://www.facebook.com/ForsMarshGroup.

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Phone-Based Screener (for those who qualify based on web-based screener)
Hello ______. Thank you for your interest in participating in user experience studies at Fors Marsh
Group. My name is ________ and I wanted to follow up regarding a web-based screener that you
completed recently for an upcoming study about a website. I wanted to ask a couple more questions
and see if we can schedule you. Your participation is completely voluntary. Do you have a few
minutes?
Q1. Can you please verify that you are over 18?
Q2. Can you tell me a little about the issues you had with financial products and services? [Open
ended. Terminate if responses are inconsistent with web screener]

Invitation:
We would like to invite you to participate in our study. We will show you a financial website and ask
you to complete tasks using the website. The entire interview should last about an hour, and you will
be paid $75 when you are done. Would you be willing to participate in this study?
Reconfirm participant’s email address.

Terminate message: both for web and phone screener
We are sorry but you do not qualify for this study. Would you like us to contact you for future studies
that you qualify for? [Radio buttons, select only one]
1. Yes
2. No

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