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 an Internet Census questionnaire that may be used in the 2020 Census. 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 200 people asked to participate in this study.

This interview will take approximately 90 minutes to complete. During the interview we will ask you to complete an Internet Census questionnaire on an electronic device and then we will ask you to respond to some questions about the Internet questionnaire and how you arrived at your answers. Also, we will ask you questions about the instructions and formatting of the questionnaire 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. As a token of 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 these recordings to improve the census questionnaire. Staff involved in this project will have access to the recordings. You may also be asked 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.

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 manager, Patricia LeBaron , at 1-800-334-8571, ext. 25204.

________________________________________________________________________________________________

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: xxxx-xxxx

Expiration Date: xx/xx/xxxx