Debt Collection Disclosure Forms Focus Groups and User Experience Study (Round 2)

Debt Disclosure Forms Screener
Web-Based Screener
Thank you for your interest in participating in a study with [INSERT FACILITY]. We are seeking
participants for focus groups about credit and debt collection. . For this specific study, we
are working on behalf of the Consumer Financial Protection Bureau, a federal government
agency. Please note that information you provide is completely anonymous. Any opinions or
comments you give will not be shared with any a debt collectors, attorneys, collection firms,
or others that try to recover debt. Your feedback will be used to help consumers like you
understand the credit and debt collection process.
The focus groups will take place at [INSERT LOCATION]. If you are interested in participating,
please complete this questionnaire. If you qualify for this study, we will contact you to
schedule a time that is convenient for you. Compensation ($75) will be provided to those
who participate.
Participation in this study is voluntary, you are not required to participate or share any
identifying information with Fors March, including name and email address, and you may
withdraw participation at any time. However, if you do not include the requested information,
you may not participate in the study.
Thank you for your interest.
Q1.

First name: [Text box]

Last name: [Text box]

Q2.

Email [Text box]

Q3.

Mobile number: [Text box]

Q4.

Alternate number: [Text box]

Q5.

What is your age as of your last birthday?

Q6.

What is your sex?
1. Male
2. Female

Q7. Are you of Hispanic, Latino, or Spanish origin?
1. No
2. Yes
Q8.

How do you describe your race? [select all that apply]

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1. White
2. Black or African-American
3. American Indian or Alaska Native
4. Asian
5. Native Hawaiian or other Pacific Islander
Q9.

What city and state do you live in? [Text box]

Q10.

What is your highest level of education? [Radio buttons, select only one]
1.
2.
3.
4.
5.

Less than a high school degree
High school degree (grade 12, diploma, or GED)
Some college (excluding technical or vocational schools)
College degree
Postgraduate degree (for example, MA, PhD, JD, MBA, MD)

Q11. Which of the following best describes what you are currently doing? [Check boxes, select all
that apply]
1. Going to high school
2. Going to community college, 2-year degree program, or trade school (either fulltime or part-time)
3. Going to a 4-year college/university (either full-time or part-time)
4. Working full-time
5. Working part-time
6. Homemaker
7. Retired
8. Not employed [skip to Q14]
Q12.

What is your occupation? [Text box]

Q13.

What industry do you work in? [Text box]

Q14.

What is your annual household income? [Radio buttons, select only one]
1. Under $20,000
2. $20,000–$39,999K
3. $40,000 –$69,999
4. $70,000–$99,999
5. $100,000 or more

Q15.

How did you hear about research opportunities with us?
1.
2.
3.
4.
5.
6.
7.
8.

Google
Facebook
Washington Post online
Washington Post paper
Express newspaper
Craigslist.org
Restaurants or Cafes in Ballston (e.g., Starbucks, Panera, Buzz Bakery)
Friend or Family - Can you tell us who referred you so we can thank them? [Text
box]

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9. Other [Text box]
Q16: Do you currently have any debt (e.g., loans, past-due bills, financing from a store or dealer)?
1. Yes
2. No [skip to Q18]
Q17. [If Q16=yes] Which of the following types of debt do you currently have? [check boxes, select all
that apply]
A credit card balance remaining after your last payment
Mortgage, home equity loan, or home equity line of credit (HELOC)
Auto loan
Student loan
Other consumer or personal loan or line of credit (other than a mortgage, auto, or
student loan)
Auto title loan
Payday loan
Legal judgment or legal expenses (child support, attorneys’ fees, etc.)
Past-due taxes
Past-due medical bill
Past-due phone, cable, internet, or other telecommunications bill
Past-due utility bill (gas, electric, etc.)
Other type of debt: ________________________________________________
Q18. In the past two years, since [April 2012], have you been contacted (whether in person, by
phone, mail or some other means) by a debt collector, an attorney, a collection firm, or others trying
to recover a debt from you? [radio buttons, select only one]
1. Yes
2. No [skip to END]
Q19. In the past two years, since [April 2012], how many times have you been contacted by a debt
collector, an attorney, a collection firm, or others trying to get you to pay a debt? [radio buttons,
select only one] [RECRUIT A MIX]
1. 1-5 times
2. 6-20 times
3. 21-50 times
4. More than 50 times
Q20. Thinking about all of the debts that you have been contacted about since [April 2012], which of
the following type(s) of debts were you contacted about? [radio buttons, select all that apply]
[RECRUIT A MIX]
A credit card balance remaining after your last payment
Mortgage, home equity loan, or home equity line of credit (HELOC)
Auto loan
Student loan
Other consumer or personal loan or line of credit (other than a mortgage, auto, or
student loan)
Auto title loan

1010 N. Glebe Road, Suite 510 | Arlington, Virginia 22201 | www.forsmarshgroup.com

Payday loan
Legal judgment or legal expenses (child support, attorneys’ fees, etc.)
Past-due taxes
Past-due medical bill
Past-due phone, cable, internet, or other telecommunications bill
Past-due utility bill (gas, electric, etc.)
Other type of debt: _______________________________________________
Q21. Thinking about all of the debts that you have been contacted about since [April 2012], who
tried to contact you concerning these debts? [check boxes, select all that apply] [RECRUIT A MIX OF
MOSTLY 3s]
1.
2.
3.
4.

The original creditor (for example, the original lender, store, or hospital)
An attorney or law officer
A collection agency
A company that owns the debt because it bought the debt from the original
creditor
5. Other or unknown type of debt collector
Q22. People may pay a debt that they are uncertain is theirs or that they do not remember
borrowing. Thinking about the most recent debt that you were contacted about, which of the
following best describes how certain you were about whether this debt was yours? [radio buttons,
select only 1] [RECRUIT A MIX OF MOSTLY 1s AND 3s, but some 2s]
1. I was reasonably certain the debt was mine
2. I was reasonably certain the debt was not mine
3. I was uncertain whether the debt was mine
This study is taking place [Insert dates]. Please enter three days and times that will be the most
convenient for you to come to our office to participate. Expect to be in our office for [60 minutes (UX);
-90 minutes (FG)].
1. Date [Text box] Time [Text box]
2. Date [Text box] Time [Text box]
3. Date [Text box] Time [Text box]
Thank you for completing this survey. We hope to be in contact with you soon about scheduling a
time for you to participate. If you have any questions please contact us at [facility info:
ux@forsmarshgroup.com or call us at 571-858-3776. You can also visit our website at
www.forsmarshgroup.com or our Facebook page: http://www.facebook.com/ForsMarshGroup].

Paperwork Reduction Act Statement [Link to new window].
According to the Paperwork Reduction Act of 1995, an agency may not conduct or sponsor,
and a person is not required to respond to a collection of information unless it displays a
valid OMB control number. The OMB control number for this collection is 3170-0024. It
expires on 12/31/2015. The time required to complete this information collection is
estimated to average approximately 3 minutes per response, including the time for
reviewing any instructions, searching existing data sources, gathering and maintaining the
data needed, and completing and reviewing the collection of information. Responding to this
1010 N. Glebe Road, Suite 510 | Arlington, Virginia 22201 | www.forsmarshgroup.com

collection of information is voluntary. Comments regarding this collection of information,
including the estimated response time, suggestions for improving the usefulness of the
information, or suggestions for reducing the burden to respond to this collection should be
submitted to the Consumer Financial Protection Bureau (Attention: PRA Office), 1700 G
Street NW, Washington, DC 20552, or by email to PRA@cfpb.gov.
Privacy Act Statement [Link to new window].
The information you provide through your responses to Fors Marsh will assist the study
sponsor, the Consumer Financial Protection Bureau (“CFPB”), in developing disclosures.
The CFPB will not obtain or access any directly identifying information from Fors Marsh
about study participants. The agency will only obtain and access de-identified results and
aggregated analyses of those results.
Information collected on behalf of the Bureau by Fors Marsh will be treated in accordance
with the System of Records Notice (“SORN”), CFPB.021 – CFPB Consumer Education and
Engagement Records, 77 F.R. 60382 at
https://www.federalregister.gov/articles/2012/10/03/2012-24311/privacy-act-of-1974as-amended.
This information will not be disclosed as outlined in the Routine Uses for the SORN. Direct
identifying information will only be used by Fors Marsh to facilitate the study and will be kept
private except as required by law.
This collection of information is authorized by Pub. L. No. 111-203, Title X, Sections 1013
and 1022, codified at 12 U.S.C. §§ 5493 and 5512.

1010 N. Glebe Road, Suite 510 | Arlington, Virginia 22201 | www.forsmarshgroup.com

Phone-Based Screener (for those who qualify based on web-based screener).
Hello ______. Thank you for your interest in participating in [focus groups/user experience studies] at
[facility]. My name is ________ and I wanted to follow up regarding a screener that you completed
recently for an upcoming study. I wanted to ask a couple more questions and see if we can schedule
you. Your participation is completely voluntary. Do you have a few minutes?
Q1.

Can you please verify your age?

Q2:
Do you currently have any debt, such as a loan, past-due bill, or financing from a store or
dealer?
1. Yes
2. No
Q3.

In the past two years, since [April 2012], have you been contacted (whether in person, by
phone, mail or some other means) by a debt collector, an attorney, a collection firm, or
others trying to recover a debt from you? [radio buttons, select only one]
1. Yes [Invite to Participate in Collections Group]
2. No [Invite to Participate in Non-Collections Group]

Focus Group Invitation:
We would like to invite you to participate in our study. We will be discussing the debt collection
process and how that can be improved. The entire session should last about 90 minutes, and you
will be paid $75 when you are done. Are you willing to participate in this study?
Reconfirm participant’s email address.
UX Session Invitation:
We would like to invite you to participate in our study. We will be discussing the debt collection
process and how that can be improved. The entire session should last about an hour, and you will be
paid $75 when you are done. Are you willing to participate in this study?
Reconfirm participant’s email address.

Terminate message: both for web screener
We are sorry but you do not qualify for this study. Would you like us to contact you for future studies
that you qualify for? [Radio buttons, select only one]
1. Yes
2. No

1010 N. Glebe Road, Suite 510 | Arlington, Virginia 22201 | www.forsmarshgroup.com