Usability Consent Form

Consent Form

For Individual Participants

Usability Testing of Hazardous Materials Incident Report form

Each year the Census Bureau conducts many different usability evaluations. For example, the Census Bureau routinely tests the wording, layout and behavior of products, such as Web sites and online applications in order to obtain the best information possible.

You have volunteered to take part in a study to improve the usability of the Hazardous Materials Incident Report form.  In order to have a complete record of your comments, your interview session will be recorded.  We will also capture your eye movements with our eye tracking technology to better understand how you are interacting with the site. We plan to use the recording and eye tracking data to improve the design of the form.  Your participation is voluntary. Your name will not be associated with any of your responses, recording or eyetracking. Only staff involved in this product design research will have access to the recording and eyetracking.

49 C.F.R. § 171.16 provides the authority to collect these data. The OMB control number for this study is 0607-0725. This valid approval number legally certifies this information collection.

I have volunteered to participate in this Census Bureau usability study, and I give permission for my recording and eyetracking data to be used for the purposes stated above.

Participant’s Name: ______________________________________

Participant's Signature: ____________________________________ Date: ­­­­­__________

Researcher’s Name: _____________________________________

Researcher's Signature: ___________________________________ Date: __________