Revised Form W4 Usability

MITRE

Participant Consent Form
ADULT CONSENT TO PARTICIPATE IN A RESEARCH STUDY

PRINCIPAL INVESTIGATOR(S): Nicholas Kohn, Ph.D.; Jamel Morris, Project Manager

STUDY TITLE: Form W-4 Redesign Usability Study

INTRODUCTION

We invite you to take part in a research study conducted by The MITRE Corporation (MITRE).

We want you to know that taking part in MITRE research is entirely voluntary.

You may choose not to take part, or you may withdraw from the study at any time.

Before you decide to take part, please take as much time as you need to ask any questions and discuss this study with anyone at MITRE, or with family, friends, or any of your advisers.

THE RESEARCH STUDY

1. Research Protocol

The purpose of this research is to learn how usable a new Form W-4 is for taxpayers. You will be given fictitious taxpayer information and asked to fill out the new Form W-4 using this fictitious information. You will then be asked some questions about your experience. You will not be asked to provide your personal financial information. Participation in this study is expected to last 60-90 minutes.

2. Risks/ Discomforts

There are no expected risks or discomforts to the participant involved in this study.

3. General or Participant Benefits

You may receive no benefit from taking part. The research may give us knowledge that may benefit the work of MITRE and its Sponsors, including the Internal Revenue Service (IRS).

OTHER PERTINENT INFORMATION

1. Confidentiality. The identities of participants will not be made known to MITRE management or to IRS employees. When results of MITRE research are reported to the IRS or other government agencies, in professional journals, or at scientific meetings, the people who take part are not named and identified. Any data used is constructed so as to preclude identifying participants.

2. Recording. This interview may be recorded by the researcher with your consent. The recording will not identify you by name, and will be destroyed upon completion of this research study.

3. Remuneration. As a token of appreciation, you will receive a $100 prepaid gift card upon completion of this research interview.

4. Problems or Questions. If you have any problems or questions about this study, or about your rights as a research participant, or about any research-related injury, contact the Principal Investigator, Nicholas Kohn, at (703) 983-0016. Other researchers you may call include: Jamel Morris, at (703) 983-6511.

5. Consent Document. Please keep a copy of this document in case you want to read it again.

Participant’s Consent

I have read the explanation about this research study and have been given the opportunity to discuss it and to ask questions. I hereby consent to take part in this study.

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Signature of Participant Date

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Signature of Principal Investigator/Researcher Date