Consent Form

American Community Survey

Adult Cognitive Interview Participant Informed Consent Form

What is the purpose of this interview?

The U.S. Census Bureau is conducting cognitive interviews to help with the design and content of the American Community Survey. The American Community Survey helps local officials, community leaders, and businesses understand the changes taking place in their communities. It is an important source of detailed population and housing information about our nation. It’s important that the questions make sense, are easy to answer, and that everyone understands the questions in the same way. You are one of about 335 people who are being asked to participate in the cognitive interviews.

What will happen if I take part in this interview?

You will be asked to complete and discuss the American Community Survey during a confidential interview. The survey includes questions about your household, including yourself and other people in the household. The interview will be conducted by a staff member from RTI International or Research Support Services, who are doing this study for the U.S. Census Bureau. Findings from the discussion will be used to clarify survey questions and instructions.

We would like to audio and video record the interview. Only the people who work on this study will view the recording. It will help us make sure we have understood your answers. If you don’t want to be recorded, that’s okay. Partcipating in the interview implies consent for the purposes stated.

How much time is required to participate?

The interview will last approximately 1 hour.

Do I have to take part in this interview?

No, participation in this interview is voluntary. You can stop the interview at any time, and you don’t have to answer a question if you don’t want to. You will not lose any rights you would normally have if you choose not to join this interview.

What are the possible risks and benefits from participating in this interview?

There are no direct benefits to you from doing this interview. Your involvement in this study will help us improve the questions for the American Community Survey. There is no more than minimal risk in participating. You can skip any question that you are not comfortable answering.

How will my privacy be protected?

This interview is being conducted under the authority of 13 U.S.C. Sections 6 (c), 141, and 193. Federal law requires that your answers are kept confidential (13 U.S.C. Section 9), and protects your privacy under the Privacy Act (5 U.S.C. Section 552a). Only research staff from the U.S. Census Bureau and its survey vendors, RTI International and Research Support Services will know your answers and/or comments from the interview. The Census Bureau can use your responses only to produce statistics, and is not permitted to publicly release your responses in a way that could identify you, your business, organization, or institution.

Additionally, per the Federal Cybersecurity Enhancement Act of 2015, your data are protected from cybersecurity risks through screening of the systems that transmit your data. Your information is secured by strictly adhering to the provisions of the Privacy Act, and other regulations and policies to protect the privacy and confidentiality of the information.

This collection has been approved by the Office of Management and Budget (OMB). This eight-digit OMB approval number, 0607-0725, confirms this approval and expires on 12/31/2022. Without this approval, we could not conduct this study.

How will I be compensated?

You will receive $40.

What if I have questions about the interview?

If you have concerns or questions about the interview, you may contact RTI’s project director, Doug Currivan, at 919-316-3334 or [email protected].

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Participant’s Agreement:

I have read the information provided above. I voluntarily agree to participate in this interview.

 I agree for this interview to be audio and video recorded.

 I do not agree for this interview to be audio and video recorded.

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Signature of Research Participant Date

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Printed Name of Research Participant

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Signature of Person Obtaining Consent Date

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Printed Name of Person Obtaining Consent

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