Various Demographic Area Pretesting Activities

Cognitive Testing of Roster, Coverage, and Address Questions for the 2020 Census

CONSENT FORM

The U.S. Census Bureau routinely tests materials used for collecting data or disseminating data in order to produce the best products possible. You are invited to participate voluntarily in this interview, which is being conducted by RTI International (RTI), a not-for-profit research firm, and Research Support Services, Inc. (RSS), a contract research firm, for the Census Bureau. The purpose of this interview is to help the Census Bureau review and improve forms used for the decennial census. You are one of up to 240 people asked to participate in this study.

This interview will take approximately 60 minutes to complete. During the interview we will ask you to complete a census form and then respond to some questions about the form and how you arrived at your answers. Also, we will ask you questions about the instructions and formatting of the form to determine how easy or difficult it was to complete. Throughout the interview you can help us by describing anything you find confusing or difficult to understand. In appreciation for your participation in this project, you will receive $40.00 at the end of the interview.

In order to have a complete record of your comments, your interview session will be audio/video-taped. We plan to use the tapes to improve the census forms. Staff involved in this project will have access to the tapes. You may also be asked to if a member of the Census Bureau project team can observe the interview in person. If this applies to you, we will ask for your permission prior to any observation taking place.

Some questions in the interview are of a personal nature (such as your date of birth) which you may find uncomfortable. While we would prefer that you answer all questions, you may skip any question or you may stop the interview at any time. Your participation in this study is voluntary. Even if you choose not to participate, you will not lose any benefits or services that you may be receiving from any governmental agency. There are no direct benefits to you for participating in this study, but your answers will help the Census Bureau improve the forms used for the decennial census.

Your participation will be kept confidential, and the information you give us will be combined with the responses of others in a summary report that does not identify you individually. We will not share any personal information you give us during the interview with any person outside the project staff at RTI, RSS, and the Census Bureau. There are no expected risks to participating in this study. All information collected on you as a study participant is protected by Title 13 of the United States Code (Sections 141, 193, 221, and 223).

If you have any questions about the study you may telephone the RTI project director, Dr. Murrey Olmsted, at 1-800-334-8571, ext. 25506. 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.

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I have read and understand the statements above. I consent to participate in this interview.

Check one of the following:

I agree to the interview and to be recorded.

I agree to the interview, but do not wish to be recorded.

Signature of participant: __________________________________________________________ Date: ___/___/___

Signature of Person Who Obtained Consent: __________________________________________ Date: ___/___/___

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OMB Control Number: 0607-0725

Expiration Date: August 31, 2013