Consent Form

Attachment D

11/4/2020

PURPOSE

The U.S. Census Bureau is conducting a short study in partnership with RTI International, a not-for-profit research organization. The Census Bureau routinely conducts research on how to collect information in order to produce the best statistics possible. You are invited to take part in this study, which seeks to help the Census Bureau improve survey questions about the impact of the Coronavirus pandemic on your company’s capital expenditure investments. If you agree to participate, you will be asked to complete a few survey questions about the pandemic’s impacts on your company and discuss how you answer these questions during a confidential interview.

AUTHORITY AND CONFIDENTIALITY

This survey is conducted by the Census Bureau under the authority of Title 13 U.S. Code (U.S.C.), Sections 131 and 182. Section 9 of Title 13 U.S.C. ensures the confidentiality of data reported by private companies. Routine 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 can use your responses only to produce statistics, and is not permitted to publicly release your responses in a way that could identify you, your business, organization, or institution. Additionally, per the Federal Cybersecurity Enhancement Act of 2015, your data are protected from cybersecurity risks through screening of the systems that transmit your data.

This study has been approved by the Office of Management and Budget (OMB). This eight-digit OMB number, 0607-0725, confirms this approval and expires on 12/31/2022. Without this approval, we could not conduct this study.

BURDEN ESTIMATE

We estimate that completing this interview will take no more than 30 minutes. 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

You have volunteered to take part in a study of data collection procedures. You will connect with our interviewer via Skype for Business for the virtual interview, in which you will answer the survey questions and then discuss the questions with the interviewer via computer audio or telephone. The interview will be conducted by a staff member from RTI International. We plan to use your feedback to improve the content, design and layout of the form.

We would like to audio record what you say during the interview. Only the people who work on this study will hear the recording, which will simply be used to ensure we have understood your answers. If you don’t want to be recorded, that’s okay.

Please Check the appropriate options below to indicate your consent.

 I have read the above, understand that my participation is voluntary, and I agree to participate.

 I agree for this interview to be audio-recorded.

 I do not agree for this interview to be audio-recorded.

 I do not agree to participate in the study.

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Signature of Research Participant Date

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Printed Name of Research Participant