Focus Group Consent Form

Consent Form

2020 Census Partnership Engagement Program (CPEP)

The U.S. Census is conducted every 10 years. The Census Bureau routinely conducts research to better understand how Census-related programs are conducted.

______________________ [NAME] consents to take part in focus group study to help better understand the 2020 Census Partnership Engagement Program. In order to have a complete record of all comments, the session will be audio recorded. The Census Bureau plans to use the tapes to help understand the U.S. Census. Participation is voluntary.

The OMB control number for this study is 0607-0971. This valid approval number legally certifies this information collection.

Privacy Act Statement

The U.S. Census Bureau is required by law to protect your information. The Census Bureau is not permitted to publicly release your statements in a way that could identify you. We are conducting this focus group under the authority of Title 13, United States Code, Sections, 6(c), 141 and 193. Federal law protects your privacy and keeps your answers confidential (Title 13, United States Code, Section 9). Your voluntary response will be used to study privacy and confidentiality concerns related to the 2020 Census.

Your privacy is protected by the Privacy Act. The information provided may be shared with other Census Bureau staff for the work-related purposes identified in this statement. For more information on this collection, see SORN “CENSUS-5, Decennial Census Programs” by visiting our website at census.gov and click on "Data Protection and Privacy Policy" at the bottom of the home page.

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

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Participant's Signature Researcher's Signature

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Printed Name Printed Name

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