Consent Form

U.S. Census Bureau

Consent Form: American Community Survey

Each year the Census Bureau conducts many different surveys. The Census Bureau routinely tests the questions used on these surveys in order to produce the best information possible.

You will be taking part in a study to improve the questions that will be used in the American Community Survey. This study is being conducted by Westat for the U.S. Census Bureau. During this interview, you will answer a series of questions and we will ask you about your reactions to some of them. There are no right or wrong answers to the questions we ask. We need approximately 60 minutes of your time. You will be paid $40 cash after the discussion to offset the cost of participation, such as transportation or childcare costs.

Your participation is voluntary and you have the right to leave at any time. You may also decline to answer any questions that we ask. The information you provide in the interview will be treated as confidential, by both Westat and the U.S. Census Bureau. You will not be identified by name in any of our summaries or reports. Your name will not be linked to any of your responses, though we may include quotes you provide in our reports. Your information will be combined with information from other respondents and presented in summary form.

In order to have a complete record of all comments, the interview session will be audio-recorded. Recordings allow us to carefully review the discussion and draw the proper conclusions. The interview may also be observed by researchers from the Census Bureau.

This study is being conducted under the authority of Title 13 USC. The OMB control number for this study is 0607-0725. This valid approval number legally certifies this information collection.

There are no direct benefits from taking part in this study. There are no known physical or psychological risks from taking part in this study.

If you have questions about how the project works, contact the Westat Project Director, Martha Stapleton at 800-937-8281, extension 4382. If you have any questions about your rights as a research subject, contact the Westat Human Subjects Protections office at (888) 920-7631. Please leave a message with your full name, the name of the research study that you are calling about (American Community Survey), and a phone number beginning with the area code.

The interviewer will be happy to answer any questions you have about the study.

If you agree to participate, please sign below.

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

• I allow my interview to be recorded.

• I do not allow my interview to be recorded.

Participant's signature Date

Participant's printed name