Black Lung Consent Form

OMB Control No. 1225-0093

Expiration Date: 02/29/2024

Consent Form

Informed Consent for Research Participation

Thanks for taking the time to speak with us. Please read the statements below and sign where indicated.

By submitting this form you are indicating that you have read the description of the study and that you agree to the terms as described.

If you have any questions, or would like a copy of this consent form, please contact (email here)

What this study is about

This interview is part of a series of interviews conducted by the Technology Transformation Service on behalf of the Department of Labor as part of a project aiming to improve the Black Lung Compensation program customer experience

Your Involvement in the Study

We will ask you questions about your experience with the Black Lung Compensation Program. With your permission, we will record you on audio and/or video, and we will take notes to document your comments. We may ask you to share your screen when describing how you use the Black Lung Compensation’s websites. The activities should take a maximum of 1 hour altogether.

Your Participation is Voluntary

Participation is completely voluntary. You may refuse to answer any questions or end participation at any time.

Confidentiality

We will take necessary and appropriate precautions to keep what you tell us confidential. We may develop and present research reports within the organization that include your anonymous comments and experiences shared. We will not use your real name in any of our materials.

Storage of Personal Information and Session Data

We will securely store and process your personal information and session data until we deem the content no longer necessary for the research purposes outlined above. This data can include your name, email address, and phone number.

Statement of Consent

I have read the above information and received answers to any questions I have asked. I consent to take part in this interview and to have any information I provide be used in the manner described above. I understand that my name will not be used in connection to my words or any recordings taken during the duration of this interview. I expressly release the Technology Transformation Service from and against any and all claims that I have or may have for invasion of privacy, defamation, or any other cause of action arising out of the production, distribution, display, or publication of the results of the project, so long as the conditions of use described above are met.

If you agree to participate in this study, please type your name in the box below.

Please also initial here if you approve of and consent to having this conversation recorded, so that the small team working on this project can also benefit from your thoughts.