Consent Form

2023 NSCH-LC Mail Materials Cognitive Interviewing Consent Form

Each year the U.S. Census Bureau conducts many different surveys.  The Census Bureau routinely tests survey questions and materials used for these surveys in order to produce the best information possible. The purpose of this research is to interview parents and caregivers of children and young adults living in the United States to assess their understanding of the proposed letters to be used for the 2023 National Survey of Children’s Health Longitudinal Cohort.

The U.S. Census Bureau is conducting this survey on behalf of the U.S. Department of Health and Human Services under Title 13, United States Code, Section 8(b), which allows the Census Bureau to conduct surveys on behalf of other agencies. The OMB control number for this study is 0607-0725 (expiration 12/31/25). This valid approval number legally certifies this information collection. An agency may not conduct (and a person is not required to respond to) an information collection request unless it displays a currently valid OMB Control Number. We estimate that completing this study will take 60 minutes on average. If you have comments or questions about this study, please email [email protected].

In order to have a complete record of your comments, your interview session will be recorded and saved in a secure location.  We will use the recordings to refresh our memories while we make recommendations on improving the materials.  Only staff directly involved in this research will have access to the recordings. The U.S. Census Bureau is required by law to protect your information and is not permitted to publicly release your responses in a way that could identify you.

Participation in this survey is voluntary and there are no penalties for refusing to answer questions. However, your cooperation in obtaining this much needed information is extremely important to ensure complete and accurate results. After completion of this session, we will send you $50 by USPS Priority Mail for your participation in this study.  Please provide your mailing address and signature below. 

Participant’s signature:

Participant’s Name:

Participant’s Mailing Address:

The U.S. Census Bureau is required by law to protect your information. We are not permitted to publicly release your responses in a way that could identify your household. The Census Bureau is conducting this survey under the authority of Title 13, United States Code (U.S.C.), Section 8(b) (13 U.S.C. § 8(b)) and Section 501(a)(2) of the Social Security Act (42 U.S.C. § 701). Federal law protects your privacy and keeps your answers confidential under Title 13, U.S.C., Section 9 (13 U.S.C. § 9). Per the Federal Cybersecurity Enhancement Act of 2015, your data are protected from cybersecurity risks through screening of the systems that transmit your data.

Under the Privacy Act of 1974 (5 U.S.C. Section 552a), these records are maintained by the Census Bureau under SORN COMMERCE/CENSUS-3, Demographic Survey Collection (Census Bureau Sampling Frame). Access to records maintained in the system is restricted to Census Bureau employees and certain individuals authorized by Title 13, U.S. Code (designated as Special Sworn Status individuals). These individuals are subject to the same confidentiality requirements as regular Census Bureau employees.