Consent Form

Attachment C: Consent form

AUTHORITY AND CONFIDENTIALITY

This collection is authorized under Title 13 U.S. Code, Sections 131 and 182. The U.S. Census Bureau is required by Section 9 of the same law to keep your information confidential and can use your responses only to produce statistics. Your privacy is protected by the Privacy Act, Title 5 U.S. Code, Section 552a. The uses of these data are limited to those identified in the Privacy Act System of Record Notice titled “COMMERCE/CENSUS-4, Economic Survey Collection.” The Census Bureau is not permitted to publicly release your responses in a way that could identify you, your business, organization, or institution. Per the Federal Cybersecurity Enhancement Act of 2015, your data are protected from cybersecurity risks through screening of the systems that transmit your data.

BURDEN ESTIMATE  We estimate that completing this interview will take 60 minutes on average, including the time for reviewing instructions, searching existing data sources (if necessary), gathering and maintaining the data needed (if necessary), and completing and reviewing the collection of information. You may send comments regarding this estimate or any other aspect of this survey, including suggestions for reducing the time it takes to complete this survey to ewd.surveys@census.gov.

CONSENT FORM The U.S. Census Bureau routinely conducts research on how we, and our partners, collect information in order to produce the best statistics possible.  You have volunteered to take part in a study of data collection procedures.

We plan to use your feedback to improve the design and layout of the form for future data collections. Only staff involved in this product design research will have access to any responses you provide. This collection has been approved by the Office of Management and Budget (OMB). This eight-digit OMB approval number, 0607-0725, confirms this approval and expires on 12/31/2022. Without this approval, we could not conduct this study.    You have volunteered to take part in a study of data collection procedures. In order to have a complete record of your comments, your interview will be recorded (e.g., audio and screen). We plan to use your feedback to improved the design and layout of survey forms for future data collections. Only staff involved in this product design research will have access to the recording.   

For each of the following, please indicate your consent.  Note that while you must give consent to participate in the research overall, you can decline the other options and still be interviewed.

	Yes (1)	No (3)
I give my consent to participate in this research. I understand that my participation is voluntary and that I can stop the interview at any time. (1)
I give my consent to have my research interview recorded, both audio and video. I understand that the recordings are for analyzing the interviews later and that neither my name nor the name of my company will be disclosed. (2)
I give my consent to have additional Census Bureau staff, beyond the interviewer, observe my interview. I understand that this staff is also sworn to uphold Title 13 of the US Code referenced above. (3)
I give my consent to share my screen with Census Bureau researchers through Skype for Business. I understand that screen sharing does not give the Census Bureau any access to any hardware, software, or applications of mine. (4)

Q9 Use your mouse or finger to sign your name in the box below.

Q7 Enter your information below:

• First Name: (1) ________________________________________________

• Last Name: (2) ________________________________________________

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