Consent form

Consent Form

For Individual Participants

Usability Testing of the Food Nutrition Supplement

Each year the Census Bureau conducts many different usability evaluations that test how participants interact with certain tools. For example, the Census Bureau routinely tests the wording, layout, and behavior of websites and online questionnaires, in order to obtain the best information possible.

You have volunteered to take part in a study to improve the usability of the online application form for the Virginia Food Nutrition Supplement. To have a complete record of your comments, your usability session will be videotaped. We plan to use the tapes to improve the design of the product. Only staff directly involved in the research project will have access to the recording. Your participation is voluntary, and your answers will remain strictly confidential.

This usability study is being conducted under the authority of Title 13 USC and 29 USC 3141. The OMB control number for this study is 0607-0978 and expires [fill expiration]. Without this number we could not collect your information.

The data you enter in the application system is for research purposes only. It is protected by the privacy policy of the Virginia Department of Social Services (VDSS). The Virginia Department of Social Services (VDSS) creates, collects, uses, maintains, and discloses Personally Identifiable Information (PII) in compliance with 45 CFR §155.260.

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

Participant’s Name: ______________________________________

Participant's Signature: ____________________________________ Date: ­­­­­__________

Researcher’s Name: _____________________________________

Researcher's Signature: ___________________________________ Date: __________