INFORMED CONSENT FORM_882T Generic Clearance

INFORMED CONSENT FORM

The U.S. Energy Information Administration (EIA) routinely tests forms used for collecting data or disseminating data in order to produce the best forms possible.

You have volunteered to take part in a study to [enter a brief description and purpose of the study]. In order to have a complete record of your comments, your interview will be [audio recorded or video recorded] using a digital device. We plan to use the recording to supplement our notes. Only staff involved in this research will have access to the recording.

[Use the following for CIPSEA protected survey: This study is being conducted under the authority of Confidential Information Protection and Statistical Efficiency Act of 2002 (CIPSEA), Title V of the E-Government Act of 2002 (Public Law 107-347).] [Use the following if it is protected by exemptions FOIA: This study will be protected and not disclosed to the public to the extent that it satisfies the criteria for exemption under the Freedom of Information Act (FOIA), 5 U.S.C. 552, the DOE regulations, 10 C.F.R. 1004.11, implementing the FOIA, and the Trade Secrets Act, 18 U.S.C. 1905.]

☐ Check here if: I consent to participate

☐ Check here if: I consent to audio/video recording

☐ Check here if: I do NOT consent to audio/video recording

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Researcher’s Signature Participant’s Signature

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Printed Name Printed Name

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Date Date