Attachment D ERS Consent Form

Attachment D

Participant Consent Form and Privacy Act Statement

CONSENT FORM

The Economic Research Service (ERS) is conducting research to increase the quality of ERS surveys. This study is intended to suggest ways to improve the procedures the ERS uses to collect survey data.

The ERS, its employees, agents, and partner statistical agencies, will use the information you provide for statistical purposes only and will hold the information in confidence to the full extent permitted by law. In accordance with the Confidential Information Protection and Statistical Efficiency Act of 2002 (Title 5 of Public Law 107-347) and other applicable Federal laws, your responses will not be disclosed in identifiable form without your informed consent. Per the Federal Cybersecurity Enhancement Act of 2015, Federal information systems are protected from malicious activities through cybersecurity screening of transmitted data. The Privacy Act notice on the back of this form describes the conditions under which information related to this study will be used by ERS employees and agents.

During this research you may be audio and/or videotaped, or you may be observed. If you do not wish to be taped, you still may participate in this research.

We estimate it will take you an average of [enter #] minutes to participate in this research (ranging from [enter #] minutes to [enter #] minutes).

Your participation in this research project is voluntary, and you have the right to stop at any time. If you agree to participate, please sign below.

Persons are not required to respond to the collection of information unless it displays a currently valid OMB control number. The OMB control number for this study is 0536-0073 and expires [enter Month, Day, Year].

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I have read and understand the statements above. I consent to participate in this study.

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Participant's signature Date

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Participant's printed name

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Researcher's signature

THE PRIVACY ACT STATEMENT AND CIPSEA PLEDGE

In accordance with the Privacy Act of 1974, as amended (5 U.S.C. 552a), you are hereby notified that this study is sponsored by the U.S. Department of Agriculture, Economic Research Service (ERS), under authority of 7 U.S.C. 2204(a). Your voluntary participation is important to the success of this study and will enable the ERS to better understand the behavioral and psychological processes of individuals, as they reflect on the accuracy of ERS information collections. The ERS, its employees, agents, and partner statistical agencies, will use the information you provide for statistical purposes only and will hold the information in confidence to the full extent permitted by law. In accordance with the Confidential Information Protection and Statistical Efficiency Act of 2002 (Title 5 of Public Law 107-347) and other applicable Federal laws, your responses will not be disclosed in identifiable form without your informed consent. Per the Federal Cybersecurity Enhancement Act of 2015, Federal information systems are protected from malicious activities through cybersecurity screening of transmitted data.