Various Demographic Pretesting Activities

Attachment F

U.S. Census Bureau Research Study

Participant Informed Consent

Qualitative Interview

You are invited to participate voluntarily in this interview, which is being conducted by RTI International, a not-for-profit research firm, and Research Support Services (RSS), a contract research firm, for the U.S. Census Bureau. The purpose of this interview is to help the Census Bureau understand more about how people respond to the census, as well as their perceptions and experiences with the 2010 Census.

The interview and discussion will take on average 60 minutes. There are no right or wrong answers to the questions we ask—we just want to ask your opinion about the type of questions asked for the census and your perceptions and experience with the census. In appreciation for your participation in this project, you will receive $40.00.

If you are selected to participate in a qualitative interview, we will ask you about your experience with the 2010 census and how you would respond to different census questions. Because the Census Bureau is interested in experimenting with a different way of doing the census, you will also be asked to complete a calendar that documents significant events that happened in your life this year.

Your participation in this study is voluntary, and you may stop at any time. Even if you choose not to participate, you will not lose any benefits or services that you may be receiving from any governmental agency. Also, you may choose not to answer any question. You will be paid $40 in appreciation for your time, even if you decide to stop the interview. Your participation will be kept confidential by RTI, RSS, and the Census Bureau, and the information you give us will be combined with the responses of others in a summary report that does not identify you as an individual. We will not share any information you give us during the interview with any person outside the project staff. There are no expected risks to participating in this study. Your identifying information is protected by Title 13 of the United States Code. For some interviews, one or more researchers from the U.S. Census Bureau will observe and take notes. These researchers designed this study and the observation will help them better understand how people respond to the census.

If you have any questions about the study you may telephone Mandy Sha at 1-800-334-8571 ext. 25266. If you have any questions about your rights as a research participant in this study, you may contact the Office of Research Protection at RTI International at 1-866-214-2043, a toll-free number.

_______________________________________________________________________________________________

The above document describing this research study has been explained to me. I agree to participate.

Please choose one of the following if Census Bureau researchers requested to observe this interview.

I agree to have Census Bureau researcher(s) observe.

I do not agree to have Census Bureau researcher(s) observe.

Signature of participant __________________________________________________ Date ____ / ____ / _______

I certify that the nature and purpose of this research have been explained to the above individual.

Signature of Person Who Obtained Consent __________________________________ Date _____/ ____ /________

The OMB control number for this study is 0607-0946. This valid approval number legally certifies this information collection. The expiration date is 06/30/2011.

Audio-taping the interview:

In order to make best use of our findings, we also request that you allow the interview to be audio-taped, through the use of a tape recorder that will be on the table. The audio-tape will only be heard by people who are working on this project. The only purpose of audio-taping is to allow us to review the interview as we document our findings. We will destroy the tapes upon completion of the project. If you would rather that your interview not be audio-taped, or if any time during the interview you decide that you would like the audio-taping to be stopped, please tell the interviewer and we will stop taping.

__________________________________________________________________________________________

I agree to allow the interview to be audio-taped and to be listened to by others who are working on this project:

Signature of participant _________________________________________ Date ____ / ____ /________

The OMB control number for this study is 0607-0946. This valid approval number legally certifies this information collection. The expiration date is 06/30/2011.

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