Cognitive Consent Form

Consent Form

For Individual Participants

Cognitive Testing of Hazardous Materials Incident Report form

Each year the Census Bureau conducts many different cognitive evaluations. For example, the Census Bureau routinely tests the wording, layout and behavior of products, such as Web sites and online applications, in order to obtain the best information possible.

You have volunteered to take part in a study to improve the Hazardous Materials Incident Report form. In order to have a complete record of your comments, your interview session will be audiotaped. We plan to use the tapes to create understandable questions and improve the form. Your participation is voluntary. Your name will not be associated with any of your responses or the recording. Only staff involved in this product design research will have access to the recording.

49 C.F.R. § 171.16 provides the authority to collect these data. The OMB control number for this study is 0607-0725. This valid approval number legally certifies this information collection.

I have volunteered to participate in this Census Bureau usability study, and I give permission for my recording to be used for the purposes stated above.

Participant’s Name: ______________________________________

Participant's Signature: ____________________________________ Date: ­­­­­__________

Researcher’s Name: _____________________________________

Researcher's Signature: ___________________________________ Date: __________