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 current Registered Nurses (RNs) and Advance Practice Registered Nurses (APRNs) (i.e. Nurse Practitioners, Clinical Nurse Specialists, Nurse Midwives, and/or Nurse Anesthetists) to assess their understanding of the questions and response options as presented in the proposed revised National Sample Survey of Registered Nurses (NSSRN) questionnaire.

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.

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 $100 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. Department of Health and Human Services (HHS), Health Resources and Services Administration (HRSA), and the National Center for Health Workforce Analysis (NCHWA) sponsors and provides oversight for the survey. Public Service Act 42 U.S.C. Section 294n(b)(2)(A) and Title 42 U.S.C. Section 295k(a)-(b) allows HHS to collect information for the purpose of understanding the nursing workforce in the United States.

This study is being conducted under the authority of Title 13 U.S. Code. The OMB control number for this study is 0607-0725. Federal law protects your privacy and keeps your answers confidential under 13 U.S.C. Section 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.

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 identified above and as permitted under the Privacy Act of 1974 (5 U.S.C. Section 552a) and SORN COMMERCE/CENSUS-7, Demographic Survey Collection (Non-Census Bureau Sampling Frame).