Consent Form

American Housing Survey Consent Form to Participate in Research

Each year the Census Bureau conducts many different surveys. The Census Bureau routinely tests the questions used on these surveys in order to produce the best information possible.

By signing this document, you consent to take part in a study to improve the questions that will be used in the American Housing Survey. In order to have a complete record of all comments, the interview session will be audiotaped. The Census Bureau plans to use the recordings to improve the questionnaire. Staff directly involved in the questionnaire design research project will have access to the recordings. Participation is voluntary and answers will remain strictly confidential.

The U.S. Census Bureau is conducting this voluntary study on behalf of the U.S. Department of Housing and Urban Development (HUD) under the authority of 12 U.S.C. Sections 1701-1, 1701z-2(g), and 1701-10a, and 13 U.S.C, Sections 8(b). Federal law requires that your answers are kept confidential (13 U.S. C. Section 9). Information provided to us may be shared for the work-related purposes in this statement, as identified in the Privacy Act System of Records Notice COMMERCE/Census -3, Demographic Survey Collection (Census Bureau Sampling Frame). 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.

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.

I have read and understand the statements above. I have agreed to participate in this Census Bureau questionnaire design study, and I give permission for my recordings to be used for the purposes stated above.

Use your mouse or finger to sign your name in the box below.

× SIGN HERE

Clear

Type today's date below:

____________________

Fill in the following information below:

First Name: ____________________

Last Name: ____________________

Email address: ____________________

PUBLIC VOUCHER FOR PURCHASES AND SERVICES OTHER THAN PERSONAL

The information that you provide in the spaces below will be used to release any incentive payments (cash or non-cash) to you. Census Bureau personnel will mail your incentive via USPS Priority Mail no later than five business days after completion of your interview. You will receive your incentive within two weeks of completion of your interview depending on mail service.

In the box below, please enter your name and the address where you want your incentive to be sent.

____________________

____________________

____________________

Finally please sign below and enter today's date.

× SIGN HERE

Clear

Type today's date below.

____________________