2020 Census CQA Consent Form

Consent Form

For Individual Participants

2020 Census Focus Groups

[Jennifer Hunter Childs;

Jasmine Luck;

Elizabeth Nichols- Privacy Notice]

This study will focus on your experience as a Customer Service Representative (CSR) for the 2020 Census. We want to better understand the experience you and callers had during the 2020 Census. Results from this focus group will be used to improve future call center operations at the U.S. Census Bureau. This focus group is being conducted under the authority of 5 U.S.C., Section 301 and 44 U.S.C., Section 3101.

A screen and audio recording of this focus group will be captured for qualitative analysis and quality assurance. Participating in the focus group implies consent for the purposes stated. Your participation is voluntary and your answers will remain strictly confidential.

Your privacy is protected under the Privacy Act (5 U.S.C, Section 552a). Only Census Bureau staff directly involved in the research project will have access to your data. Your information is secured by the Census Bureau by strictly adhering to the provisions of the Privacy Act, and other regulations and policies to protect the privacy and confidentiality of the information.

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

Participant’s Name: ______________________________________

Participant's Signature: ____________________________________ Date: ­­­­­__________

Researcher’s Name: _____________________________________

Researcher's Signature: ___________________________________ Date: __________