Consent Form

CONSENT FORM

The U.S. Census Bureau routinely conducts research on how we, and our
partners, collect information in order to produce the best statistics possible.
You have volunteered to take part in a study of data collection procedures. In
order to have a complete record of your comments, your interview will be audiorecorded. We plan to use your feedback to improve the design and layout of the
form for future data collections. Only staff involved in this product design
research will have access to the recording.
This study is being conducted under the authority of Title 13 USC. The OMB
control number for this study is 0607-0978. This valid approval number legally
certifies this information collection.

I have volunteered to participate in this U.S. Census Bureau study, and I
give permission for my audio recordings to be used for the purposes
stated above.
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Participant’s Signature

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Researcher’s Signature

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Printed Name

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Printed Name

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Date

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Date

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