Consent Form

Consent Form
Study of Mobile UI Design Framework for Survey Operations

I understand that the collection of my personal information for this research project, Study of
Mobile UI Design Framework for Survey Operations, is authorized under 13 U.S.C. section 182.
The OMB control number for this study is 0607-0725. This valid approval number legally
certifies this information collection.
I have received the Privacy Act Statement, and have been informed of the type of personally
identifiable information that may be collected. I understand that providing this information is
voluntary; the information is to be collected for research purpose only; the information will
remain confidential; and only those research staff who are directly involved in this project will
have access to the information.
I have volunteered to participate in this U.S. Census Bureau research project, and I give
permission for the collection of my personal information used for the purposes stated above.

Participant’s Name: ______________________________________
Participant's Signature: ____________________________________

Date: __________

Researcher’s Name: _____________________________________

Researcher's Signature: ___________________________________ Date: __________