Various Demographic Area Pretesting Activities

Federal Statistical System Public Opinion Survey

Consent Form

Each year the Federal Statistical System conducts many different surveys. We routinely test the questions used on these surveys in order to produce the best information possible.

You have volunteered to take part in a study to improve the questions that will be used in the Federal Statistical System Public Opinion Survey. In order to have a complete record of your comments, your interview session will be audiotaped. We plan to use the tapes to improve the questionnaire. Your participation is voluntary. Your name will not be associated with any of your responses. Only staff directly involved in the questionnaire design research project will have access to this information and the audio tapes will be destroyed after the analysis is completed.

This study is being conducted under the authorities of Titles 13, 42, and 26 of the USC, for the Census Bureau, the National Center for Health Statistics and the Internal Revenue Service, respectively. The OMB control number for this study is 0607-0725. This valid approval number legally certifies this information collection.

I have volunteered to participate in this Federal Statistical System questionnaire design study, and I give permission for my tapes to be used for the purposes stated above.

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Researcher's Signature Participant's Signature

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Researcher’s Name Participant’s Name

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