2014 Ethnographies and Focus Groups

DEFENSE HUMAN RESOURCES ACTIVITY

FEDERAL VOTING ASSISTANCE PROGRAM

4800 MARK CENTER DRIVE, SUITE 03J25-02

ALEXANDRIA, VA 22350-4000

PARTICIPANT CONSENT FORM

Principal Investigator: David Mermin, Partner, Lake Research Partners, Berkeley, CA

Phone: 510-379-5180

E-mail: [email protected]

Project Purpose and Procedures:

The study you are being asked to participate in, on behalf of the Federal Voting Assistance Program, involves research related to voting and elections. We will ask you to show us the steps you took to complete the voting process; your participation will be video and audio recorded. The information we collect from you will be used for research purposes only.

Your participation in this study should take no longer than 120 minutes. This is the only time we will ask for your participation in this study.

Risks:

There are no foreseeable risks of participating in this study.

Confidentiality:

We respect your privacy and will make every effort to protect your confidentiality. Identifying information such as your name, address, e-mail or phone number will not be used in association with the data used in reporting.

We will take the following steps to keep your personally identifiable information (PII) confidential and private in this study:

• The data collected about you will be kept private to the extent allowed by law.

• Your name, rank, birth date, or medical records will not be collected during the interview.

• Your name will not be in the audio or video recording. To protect your privacy, audio and video recordings will be kept under a code number rather than a name. Recordings will be kept in locked files until they are destroyed, and only study staff will be allowed to review them.

• The audio recordings of your interview will be transcribed within two weeks of the interview. Transcriptions will not contain your name, and will be kept under a code number rather than by a name. Any PII that you mention during the interview will be removed from the transcript. Your name and any other fact that might point to you will not appear in any research reports and will not appear when the results are published or presented.

• The OUSD(P&R) Human Research Protection Program (HRPP) has the right to review study records to make sure that this research is being carried out in the proper way.

Rights of the Participant:

• Your participation is voluntary, and refusal to participate carries no penalty.

• You are also free to discontinue participation at any time during this study, without penalty.

• You do not have to answer any particular question if you do not want to. You do not have to give the interviewer an explanation.

• Any PII that could identify you will be removed before results are made public.

• We will give you a copy of this consent form to keep.

• You do not waive any of your legal rights by giving consent for this interview.

Questions About the Study:

Should you have any questions or concerns related to this research, please do not hesitate to call or e-mail the principal investigator at the number/e-mail address listed at the top of this form.

Please read the following information and check the appropriate box indicating your consent or non-consent. Please sign the bottom of this sheet.

• I agree to participate in this research study.

• I do not agree to participate in this research study.

We will be video and audio recording the session with your permission. A transcript from the audio recording and parts of the video recording may be used in a report to inform policymakers and other interested parties. Please check one of the boxes below.

• I agree to have the session video and audio recorded and possibly used in an internal report as described above.

• I do not agree to have the session video and audio recorded.

Interview control number:______________ Interviewer:________________________

AGENCY DISCLOSURE NOTICE: As previously stated, your participation in this information collection is estimated to average 120 minutes. Send comments regarding this time estimate or any other aspect of this collection of information, including suggestions for reducing the burden, to the Department of Defense, Washington Headquarters Services, Executive Services Directorate, Information Management Division, 4800 Mark Center Drive, East Tower, Suite 02G09, Alexandria, VA 22350-3100 (0704-XXXX). Respondents should be aware that notwithstanding any other provision of law, no person shall be subject to any penalty for failing to comply with a collection of information if it does not display a currently valid OMB control number.

OMB Control Number: 0704-XXXX

Expiration Date: XX/XX/XXXX

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