Consent Form

Survey Materials Pretesting

Consent Form

National Survey of Children’s Health Screener Testing

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

You have volunteered to take part in a study to improve the materials used in the National Survey of Children’s Health. In order to have a complete record of your comments, your interview session will be audiotaped. We plan to use the tapes to improve the materials. Only staff directly involved in the materials research project will have access to the tapes. Your participation is voluntary and your answers will remain strictly confidential.

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

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Researcher's Signature Participant's Signature

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Researcher’s Name Participant’s Name

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