Attachment C - ACS Respondent Burden Testing_Consent Form_FINAL

U.S. Census Bureau

Consent Form: Census Bureau mailings study

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.

You will be taking part in a study to find out what people think about the mail they receive from the Census Bureau. This study is being conducted by Westat for the U.S. Census Bureau. During this interview, we will ask you about your reactions to different mailing materials. There are no right or wrong answers to the questions we ask. We need approximately one hour of your time. You will be paid $40 cash after the discussion.

Your participation is voluntary and you have the right to stop at any time. You may also decline to answer any questions that we ask. The information you provide in the interview will be treated as confidential, by both Westat and the U.S. Census Bureau (Title 13, Section 9). You will not be identified by name in any of our summaries or reports. Your name will not be linked to any of your responses, though we may include quotes you provide in our reports. Your information will be combined with information from other participants and presented in summary form.

In order to have a complete record of all comments, the interview session will be audio-recorded. Recordings allow us to carefully review the discussion and draw the proper conclusions. The interview may also be observed by researchers from the Census Bureau.

This study is being conducted under the authority of Title 13 USC. 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. If this number was not displayed, we could not conduct this survey. We estimate that this survey will take about 60 minutes. There are no direct benefits from taking part in this study. There are no known physical or psychological risks from taking part in this study.

If you have questions about how the project works or comments about the burden, contact the Westat Project Director, Martha Stapleton at 800-937-8281, extension 4382. If you have any questions about your rights as a research subject, contact the Westat Human Subjects Protections office at 888-920-7631. Please leave a message with your full name, the name of the research study that you are calling about (Census Bureau mailings study), and a phone number beginning with the area code.

The interviewer will be happy to answer any questions you have about the study.

If you agree to participate, please sign below.

I have read and understand the statements above. I consent to participate in this study.

• I allow my interview to be recorded.

• I do not allow my interview to be recorded.

Participant's signature Date

Participant's printed name