consent form

Consent Form

For Individual Participants

Qualitative Pretesting of the Census Notification Materials and Online Questionnaire

Each year the Census Bureau conducts many different usability evaluations. For example, the Census Bureau routinely tests the wording, layout and behavior of products, such as Web sites and online surveys and questionnaires in order to obtain the best information possible.

You have volunteered to take part in a 60-minute study that has two purposes: 1) to improve the emails that will be used for the decennial census and 2) to improve the usability of a version of the decennial census online instrument. If you have any questions about the burden estimate or any other aspects of the burden, you can contact [email protected]. In order to have a complete record of your comments, your session will be audio recorded and videotaped. Only staff directly involved in the research project will have access to the recordings. Your participation is voluntary and your answers will remain strictly confidential.

The OMB control number for this study is 0607-0725. This valid approval number legally certifies this information collection.

Privacy Notice

The U.S. Census Bureau is required by law to protect your information. The Census Bureau is not permitted to publicly release your statements in a way that could identify you. We are conducting this session under the authority of 13 U.S.C. Sections 141 and 193. Federal law keeps your answers confidential (13 U.S.C., Section 9). Your voluntary response will be used to improve mailing materials and the usability of a Census Bureau online instrument.

Your privacy is protected by the Privacy Act (5 U.S.C., Section 552a). The information provided may be shared with other Census Bureau staff for the work-related purposes identified in this statement. Participating in this focus group implies consent for the purposes stated. The Census Bureau strictly adheres to the provisions of the Privacy Act.

I have volunteered to participate in this Census Bureau study, and I give permission for my audio and screen captures to be used for the purposes stated above.

Participant’s Name: ______________________________________

Participant's Signature: ____________________________ Date: ­­­­­__________

Researcher’s Name: _____________________________________

Researcher's Signature: ___________________________ Date: __________