Consent form

Appendix E: CONSENT FORM

Form Approved

OMB No. 0607-0978

Exp. Date 08/31/2020

INFORMED CONSENT FORM

We ask that you take part in an information collection. This form describes the purpose, benefits, and risks of the information collection. It also describes your right to withdraw at any time. A member of the project staff will read through this form with you and discuss all the information if you like.

Why are you collecting this information?

We are collecting information to understand how people make decisions about responding to the U.S. census. Y&R, an advertising agency, and its partners are conducting this project for the U.S. Census Bureau. The findings will inform the development of an advertising campaign.

What do I need to know about this project?

Adults age 18 and older are able to participate. If you choose to participate, the project team will tell you when and where your focus group will meet. During the focus group, the moderator will ask you to share your thoughts and attitudes about the census. The focus group will last about 90 minutes. There are no costs associated with your participation. You do not have to answer any questions that you do not want to.

In accordance with the Paperwork Reduction Act of 1995, the federal government’s Office of Management and Budget (OMB) has approved the questions asked through this project. The OMB control number is XXX. Without this approval, we could not ask these questions.

Members of the project team will observe the session, either in-person or remotely. Members of the sponsoring agency may also observe the session, either in-person or remotely. The observers will take notes and listen, but they will not bother you. You will only talk to the moderator and a small group of other participants.

What are the potential risks of being in the focus group?

There are minimal risks associated with this project. Breach of confidentiality is possible, but the risk is reduced because your responses are not linked to your name or other identifying information. Instead, we will use a code, and the project team agrees to protect your privacy. You do not have to answer any questions that you do not want to answer.

Does participating in this project provide any benefit?

There is no direct benefit to you in participating in this project. The information from the focus groups will help us decide what ideas and messages might be useful in educational outreach about the U.S. census.

Will it cost me anything to participate in the project?

There are no costs to participate in the project, other than possible transportation costs to and from the facility. Participants in the focus groups will receive $75 for their participation.

Do I have to be in this project?

Your participation is voluntary, which means you can stop at any time.

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Who will see the results of this project or my information?

The research team will hear everything you say during the focus group. We will be very careful to only let people working on the project see your information. There is a small risk that others might find out what you say, despite all of our best efforts. In this, appropriate steps will be taken to notify participants.

The focus group will be audio- and video-recorded and transcribed. It might also be livestreamed so that other members of the project team or members of the sponsoring agency who could not travel can watch remotely. You will be told at the start of the focus group whether it is being livestreamed. By signing this form, you consent to being recorded and livestreamed during the focus group.

Your name and other personal information will not be linked to your responses and will not be shared with the sponsoring agency. This means that no one outside of the project team will be able to trace what you said back to you. Everything you share will be kept private to the extent allowed by law. This means that we will not share anything you provide with anyone outside the project unless it is required to protect you, or if required by law. However, if you show a direct threat of harm to yourself or others, we have the right to take action out of concern for you and concern for others.

All of the information we collect, including anything you say in the focus group, information collected during screening, audio files, video files, and transcripts will be stored on a password-protected computer or in locked cabinets that only the project team can access. After three years, all of the collected information will be destroyed by securely shredding documents or permanently deleting electronic information.

Results from this project may appear in professional journals or scientific conferences or shared with other project teams. No individual participants will be identified or linked to the results. We will not disclose your identity in any report or presentation.

What if I have questions about the project?

If you have questions or concerns about the project, you can contact James Poumade. James is the project director at Y&R. You can reach him by email at james.poumade@yr.com or by phone at 202-530-4762. You can ask questions about this consent form or the project at any time. This includes before you decide to start the project, at any time during the project, and after the project is complete. If you decide to start the project and then change your mind, you can stop participating at any time without penalty or loss of benefits.

Are my answers confidential?

Yes. The U.S. Census Bureau is required by law to protect your information (13 U.S.C. § 9 and

§ 214). The Census Bureau is not permitted to publicly release your responses in a way that could

identify you or your household.

Please mark a box and sign below. By signing this form, you have not waived any of your legal rights.

Yes, I agree to participate in this project. I have read, understand, and had time to consider all of the information above. My questions have been answered, and I have no further questions.

No, I do not agree to participate in this project. I have read, understand, and had time to consider all of the information above. My questions have been answered, and I have no further questions.

Signature Date

If you would like a copy of this form for your records, please ask the project team.

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