Consent Form

OMB Control Number 3041-XXXX
Expiration Date xx/xx/xxxx

Consent Form

PRIVACY ACT STATEMENT
In accordance with the Privacy Act of 1974 (Public Law 93-579), this notice informs you of the
purpose of the survey and how the findings will be used. Please read it carefully.
AUTHORITY: 10 U.S.C. 503, 2358
PRINCIPAL PURPOSE: Information collected in this survey will be used to help Consumer
Product Safety Commission staff improve the communication of hazards associated with
consumer products.
ROUTINE USES: None.
DISCLOSURE: Providing information on this survey is voluntary. There is no penalty if you
choose not to respond. However, your maximum participation is encouraged so that the data
collected will be complete and representative. Your survey instrument will be treated as
confidential. Personally identifiable information (PII) will be used only by persons engaged in,
and for the purposes of, the survey. Only group statistics will be reported.
(a) I wish to continue
(b) I do not wish to continue
(c) Refused
If (b) or (c), respondent was an INELIGIBLE respondent.
If (a), proceed to next page.