Consent Form

Consent Form

OMB Control Number: 1220-0141

Expiration Date: March 31, 2021

The Bureau of Labor Statistics (BLS) is conducting research to increase the quality of BLS surveys. This study is intended to suggest ways to improve the procedures the BLS uses to collect survey data.

The BLS, its employees, agents, and partner statistical agencies, will use the information you provide for statistical purposes only and will hold the information in confidence to the full extent permitted by law. In accordance with the Confidential Information Protection and Statistical Efficiency Act of 2002 (Title 5 of Public Law 107-347) and other applicable Federal laws, your responses will not be disclosed in identifiable form without your informed consent. Per the Federal Cybersecurity Enhancement Act of 2015, Federal information systems are protected from malicious activities through cybersecurity screening of transmitted data. The Privacy Act notice on the back of this form describes the conditions under which information related to this study will be used by BLS employees and agents.

During this research you may be audio and/or videotaped, or you may be observed. If you do not wish to be taped, you still may participate in this research.

We estimate it will take you an average of xx minutes to participate in this research..

Your participation in this research project is voluntary, and you have the right to stop at any time. If you agree to participate, please sign below.

Persons are not required to respond to the collection of information unless it displays a currently valid OMB control number. OMB control number is 1220-0141 and expires March 31, 2021.

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

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Participant's signature Date

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Participant's printed name

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Researcher's signature

PRIVACY ACT STATEMENT

In accordance with the Privacy Act of 1974 as amended (5 U.S.C. 552a), this study is being conducted by the U.S. Department of Labor, Bureau of Labor Statistics (BLS), under the authority of 29 U.S.C. 2.  Your voluntary participation is important to the success of this study and will enable the BLS to better understand the behavioral and psychological processes of individuals, as they reflect on the accuracy of BLS information collections.  The information will only be used by and disclosed to BLS personnel and contractors who need the information for activities related to improving BLS information collection.  Information on routine uses can be found in the system of records notice,  DOL/BLS – 14, BLS Behavioral Science Research Laboratory Project Files (81 FR 47418).