Consent Form

Consent Form

For Individual Participants

Annual Capital Expenditures Survey

Each year the Census Bureau conducts many different evaluations. For example, the Census Bureau routinely tests the wording, layout and behavior of products, such as Web sites and surveys in order to obtain the best information possible.

You have volunteered to take part in a study to improve the Annual Capital Expenditures Survey. In order to have a complete record of your comments, your interview session may be recorded. We plan to use the recording to improve the survey. Only staff directly involved in the research project will have access to the recording. Your participation is voluntary and your answers will remain strictly confidential.

This evaluation 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.

I have volunteered to participate in this Census Bureau study, and I give permission for my recording to be used for the purposes stated above.

Participant’s Name (print): ______________________________________

Participant's Signature: ____________________________________ Date: ­­­­­__________

Researcher’s Name (print): _____________________________________

Researcher's Signature: ____________________________________ Date: ­­­­­__________