Consent Form

Consent Form
For Individual Participants
Evaluation of the Commodity Flow 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 the Commodity Flow 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 usability study, and I give
permission for my tapes to be used for the purposes stated above.

Participant’s Name (print):

______________________________________

Participant's Signature:

____________________________________

Researcher’s Name (print):

_____________________________________

Researcher's Signature:

____________________________________

Date: __________

Date: __________