Consent

Pre-decisional, Deliberative, Not for Distribution

OMB Race and Ethnicity Cognitive Testing

Adult Cognitive Interview Participant Informed Consent Form

What is the purpose of this interview?

The U.S. Census Bureau is conducting cognitive interviews to test changes to questions asking about race and ethnicity that may be used across many federal surveys. It is important to ensure the comparability of race and ethnicity data throughout the Federal Government as it is a meaningful source of detailed population information about our nation. The questions ask about yourself and others in your household. It’s important that the questions make sense, are easy to answer, and that everyone understands the questions in the same way. You are one of about 100 people who are being asked to participate in the cognitive interviews.

What will happen if I take part in this interview?

The confidential interview will be conducted by a staff member from RTI International or Research Support Services, who are doing this study for the U.S. Census Bureau. During the interview, the interviewer will ask you questions about yourself and others in your household, and will then ask for your opinions about the survey questions. Findings from the interview will be used to clarify survey questions and intructions.

We would like to video record the interview. Only the people who work on this study will view the recording. It will help us make sure we have understood your answers.

How much time is required to participate?

The interview will last approximately 1 hour.

Do I have to take part in this interview?

No, participation in this interview is voluntary. You can stop the interview at any time, and you don’t have to answer a question if you don’t want to. You will not lose any rights you would normally have if you choose not to join this interview.

What are the possible risks and benefits from participating in this interview?

There are no direct benefits to you from doing this interview. Your involvement in this study will help improve race and ethnicity questions that may be used across many federal surveys. There is no more than minimal risk in participating. If any of the questions make you feel uncomfortable or upset, you may take a break or stop the interview.

How will my privacy be protected?

By law, the Census Bureau is required to keep your answers confidential. This survey is voluntary and you may refuse to answer any question. The results of this study may be used to inform future surveys and censuses. This collection has been approved by the Office of Management and Budget (OMB). This eight-digit OMB approval number, 0607-0725, confirms this approval. We are required to display this number to conduct this survey. By proceeding with this study, you give your consent to participate in this study.

The U.S. Census Bureau is conducting this study under the authority of 13 U.S.C. Sections 131, 141, 182, 193, and 196. Your privacy is protected by the Privacy Act of 1974 (5 U.S.C. Section 552a).. There are a limited number of uses of your data that are permitted under the Privacy Act. You can find a list of these uses in the System of Records Notice (SORN). For this survey, the SORNs are named: COMMERCE/Census -3, Demographic Survey Collection (Census Bureau Sampling Frame); COMMERCE/CENSUS-5, Decennial Census Programs; and COMMERCE/CENSUS-4, Economic Survey Collections.

How will I be compensated for my time?

You will receive a $40 electronic Visa gift card for your participation.

What if I have questions about the interview?

If you have concerns or questions about the interview, you may contact RTI’s project director, Victoria Dounoucos, at 919-485-7738 or [email protected].

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Participant’s Agreement:

I have read the information provided above. I voluntarily agree to participate in this interview and agree for this interview to be video recorded.

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Signature of Research Participant Date

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Printed Name of Research Participant

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Signature of Person Obtaining Consent Date

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Printed Name of Person Obtaining Consent

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