Various Demographic Area Pretesting Activities

Federal Statistical System Public Opinion Focus Group

Consent Form

Each year the Federal Statistical System conducts many different surveys. We routinely conduct focus group discussions to insure that we are asking the right questions, in the best possible way, on these surveys.

You have volunteered to take part in a study to produce 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 create understandable questions and 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. If you have questions following this session, you may contact Michelle Smirnova (michelle.smirnova@census.gov) at (301) 763-9060 or Paul Scanlon (paul.scanlon@census.gov) at (301) 763-7577.

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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