QID Video Recording Consent Form

OMB No. 0535-0248

Approval Expires: 04/30/2022

U.S. Department of Agriculture

National Agricultural Statistics Service

Video Recording Consent Form

The National Agricultural Statistics Service (NASS) routinely tests products used for collecting data or disseminating data in order to produce the best products possible. You are volunteering to be interviewed for a study to evaluate the <survey and/or project name>. The interview will last approximately <number of minutes>. Your participation is voluntary and you may stop at any time.

We will use your interview to improve the current survey and to conduct additional research on the usability of our survey materials. In order to have a complete record of your comments and to be able to study your comments more carefully, we would like to video record your interview. We also may use the recording to train staff.

You will be asked below to consent to the video-recording. If you do not wish to be video recorded, we will ask permission to audio record your interview. You may ask to stop the recording at any time, and we will turn off the recorder. If you decide to stop recording, we will ask your consent to retain the portion already recorded. If you do not wish to be video or audio recorded, you may still participate in this research.

Your interview and the recording will be used only as described above. They will be kept confidential. They will be used and viewed only by persons working for or cooperating with NASS who have signed a confidentiality form that states that no confidentially reported information will be compromised. All information collected by NASS under a pledge of confidentiality is protected by law. Any person who willfully discloses ANY identifiable information about you or your operation is subject to a jail term, a fine, or both. This study is conducted in accordance with the Confidential Information Protection provisions of Title V, Subtitle A, Public Law 107-347 and other applicable Federal laws. For more information on how we protect your information please visit: https://www.nass.usda.gov/confidentiality.

Please Read and Sign Below if You Agree

 I have volunteered to participate in this NASS study, and I give permission for this study interview to be video recorded and used for the purposes described above.

 I have volunteered to participate in this National Agricultural Statistics Service study, and I give permission for this study interview to be audio recorded only and used for the purposed described above.

 I do not wish to have the interview video or audio-recorded for any purpose, but will participate in the study.

___________________________________ ____________________________________

Participant’s Signature Researcher/Interviewer’s Signature

___________________________________ ____________________________________

Printed Name Printed Name

_____________________ _________________________

Date Date

According to the Paperwork Reduction Act of 1995, an agency may not conduct or sponsor, and a person is not required to respond to, a collection of information unless it displays a valid OMB control number. The valid OMB control number for this information collection is 0535-0248. The time required to complete this information collection is estimated to average 2 minutes per response, including the time for reviewing instructions, searching existing data sources, gathering and maintaining the data needed, and completing and reviewing the collection of information.