A2 Consent Form

Multilingual Research for 2020 Census Questionnaires

CONSENT FORM

The Census Bureau counts people in the U.S. Population. The purpose of the interview is to evaluate the design of a mobile app that is going to be used by Census interviewers to collect the household information from a person when they are right at their house. You are invited to participate voluntarily in this interview, which is being conducted by RTI International (RTI), a not-for-profit research firm, and Research Support Services, Inc. (RSS), a contract research firm, for the Census Bureau. You are one of up to 160 people asked to participate in this study.

This interview will take approximately 90 minutes to complete. During the interview we will work together to complete an online census form on a mobile device and then I will ask you to respond to some questions about the form and how you arrived at your answers. Also, we will ask you questions about the instructions and formatting of the form to determine how easy or difficult it was to complete. We may also ask you to provide comments on additional materials. Throughout the interview you can help us by describing anything you find confusing or difficult to understand. In appreciation for your participation in this project, you will receive $60.00 at the end of the interview.

In order to have a complete record of your comments, your interview session will be audio and video recorded. We plan to use the audio recordings to improve the census forms. Staff involved in this project will have access to the tapes. You may also be asked to if a member of the Census Bureau project team can observe the interview in person. If this applies to you, we will ask for your permission prior to any observation taking place.

[For Part 2a interviews:] We will have you use the mobile app to complete a household interview. For the interview, an RTI/RSS employee will play the part of the person who answers the door and answers the survey questions and you will play the part of the census interviewer who uses the app on a smartphone to ask the Census questions. Some questions in the interview are of a personal nature (such as date of birth) which you may find uncomfortable. While we would prefer that you ask all the Census questions, you may skip any question or you may stop the interview at any time.

[For Part 2b interviews:] Some questions in the interview are of a personal nature (such as date of birth) which you may find uncomfortable. While we would prefer that you answer all questions, you may skip any question or you may stop the interview at any time.

Your participation in this study is voluntary. Even if you choose not to participate, you will not lose any benefits or services that you may be receiving from any governmental agency. There are no direct benefits to you for participating in this study, but your answers will help the Census Bureau improve the forms used for the decennial census. Your participation will be kept confidential, and the information you give us will be combined with the responses of others in a summary report that does not identify you individually. We will not share any personal information you give us during the interview with any person outside the project staff at RTI, RSS, and the Census Bureau. There are no expected risks to participating in this study. All information collected on you as a study participant is protected by Title 13 of the United States Code (Sections 141, 193, 221, and 223).

If you have any questions about the study you may telephone the RTI project director, Mandy Sha, at 1-800-334-8571, ext. 25266. If you have any questions about your rights as a research participant in this study, you may contact the Office of Research Protection at RTI International at 1-866-214-2043, a toll-free number.

________________________________________________________________________________________________

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

Check one of the following:

I agree to the interview and to be recorded.

I agree to the interview, but do not wish to be recorded.

Signature of participant: __________________________________________________________ Date: ___/___/___

Signature of Person Who Obtained Consent: __________________________________________ Date: ___/___/___

ID: _____________________________

OMB Control Number: 0607-0725

Expiration Date: 8/31/16