Generic Consent - Instrument Collection

APPENDIX C: Data Instrument Collection Testing Participation Generic
Consent Form12
In accordance with the Privacy Act of 1974, as amended (5 U.S.C. 552a), you are hereby notified that this
study is sponsored by the National Aeronautics and Space Administration (NASA) Office of Education
Infrastructure Division (OEID), under authority of the Government Performance and Results Modernization
Act (GPRMA) of 2010 that requires quarterly performance assessment of Government programs for purposes
of assessing agency performance and improvement. Your participation is important to the success of this
study. The information we collect will help us improve the nature of NASA education project activities and
the accuracy with which NASA Office of Education can report to the stakeholders about the project activities
offered. The NASA OEID will use the information provided for statistical purposes related to data collection
instrument development only and will hold the information in confidence to the full extent permitted by law.
Information will be secured and removed from this server and location upon guidelines set out by the NASA
Records Retention Schedule 1392, 68-69. Although the following efforts will be taken to ensure
confidentiality, there remains a remote risk of personal data becoming identifiable. A non-identifying code
number will be assigned to participants’ data records, which will be stored in accordance with federal
regulatory procedures and accessible only to the investigator. Any use of individual data to illustrate specific
assessment results will be labeled in a manner to preserve the participants’ anonymity. In no way does
refusing participation in this instrument development study preclude you from eligibility for NASA education
project activities now or in the future.

Introduction
This research seeks to support the mission of the NASA Office of Education by asking you to take
part in a (focus group/cognitive interview/ instrument development testing) pertaining to our
interest in the ways in which NASA project activities impact outcomes for participants.13 The
information we collect will help us to improve the nature of the project activity and the accuracy
with which NASA Office of Education can report to the community about the project activities it
offers.
Purpose of the Study
Determine the degree to which this instrument accurately captures the ways participant outcomes
are measured by this data collection instrument.
Description of Study Procedures
Participants will be asked to complete XXX.
There are no foreseeable risks to participants electing to participate in this study.
Estimation of Time Required
We estimate it will take you an average of [enter #] minutes to participate in this research (ranging from
[enter #] minutes to [enter #] minutes).
Securing Your Responses
Under no circumstances will the results of your surveys be shared with anyone without your
explicit permission. The results of this research may be presented at meetings or in publications,
12

Once approved by OMB, this form will be submitted to NASA Forms Management according to NASA Policy
Directive (NPD) 1420. Thus, this form, and all others used under this clearance, will have both an OMB control
number and an NPD 1420 control number that also restricts access to NASA internal users only.
13
This clearance package is to obtain permission to develop instruments to be used in testing that will be approved
by OMB first for inclusion under this clearance prior to testing.

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however your identity will not be disclosed. Presentations and manuscripts typically contain
participants’ quotes, but participants are never identified by name. Your involvement in the
development of this instrument is entirely voluntary and you have the right to discontinue
participation at any time.
Contact Persons
If you have any additional questions concerning the research, this informed consent, or
confidentiality of responses, please contact Dr. Lisa E. Wills, Education Research Manager, at
[email protected] or call (202)258-6021.
~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~

I have read and understand the contents of this study information and informed consent form and
have been encouraged to ask questions. I have received answers to the questions I have asked. I
give my consent to participate freely in this research. I have signed and retained a copy of the
information and consent form for my records and future reference. I have signed and submitted
this information and consent form for the researcher’s records.

Participant's signature

Date

Participant's printed name

Researcher's signature

OMB Control Number: XXXX-XXXX
Expiration Date: [enter expiration date]
HQ-Form-XXXX MM/YYYY

PREVIOUS EDITIONS ARE OBSOLETE
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