Generic Consent. Data Instrument Collection Testing (6-29-21)

APPENDIX C: Data Instrument Collection Testing Participation Generic Consent Form¹²

In accordance with the Privacy Act of 1974, as amended (5 U.S.C. 552a), you are hereby notified that this study is sponsored by the National Aeronautics and Space Administration (NASA) Office of Education Infrastructure Division (OEID), under authority of the Government Performance and Results Modernization Act (GPRMA) of 2010 that requires quarterly performance assessment of Government programs for purposes of assessing agency performance and improvement. Your participation is important to the success of this study. The information we collect will help us improve the nature of NASA education project activities and the accuracy with which NASA Office of Education can report to the stakeholders about the project activities offered. The NASA OEID will use the information provided for statistical purposes related to data collection instrument development only and will hold the information in confidence to the full extent permitted by law. Information will be secured and removed from this server and location upon guidelines set out by the NASA Records Retention Schedule 1392, 68-69. Although the following efforts will be taken to ensure confidentiality, there remains a remote risk of personal data becoming identifiable. A non-identifying code number will be assigned to participants’ data records, which will be stored in accordance with federal regulatory procedures and accessible only to the investigator. Any use of individual data to illustrate specific assessment results will be labeled in a manner to preserve the participants’ anonymity. In no way does refusing participation in this instrument development study preclude you from eligibility for NASA education project activities now or in the future.

Introduction

This research seeks to support the mission of the NASA Office of STEM Engagement by asking you to take part in a (focus group/cognitive interview/ instrument development testing) pertaining to our interest in the ways in which NASA project activities impact outcomes for participants.¹³ The information we collect will help us to improve the nature of the project activity and the accuracy with which NASA Office of STEM Engagement can report to the community about the project activities it offers.

Purpose of the Study

Determine the degree to which this instrument accurately captures the ways participant outcomes are measured by this data collection instrument.

Description of Study Procedures

Participants will be asked to complete XXX.

There are no foreseeable risks to participants electing to participate in this study.

Estimation of Time Required

We estimate it will take you an average of [enter #] minutes to participate in this research (ranging from [enter #] minutes to [enter #] minutes).

Securing Your Responses

Under no circumstances will the results of your surveys be shared with anyone without your explicit permission. The results of this research may be presented at meetings or in publications,

¹² Once approved by OMB, this form will be submitted to NASA Forms Management according to NASA Policy Directive (NPD) 1420. Thus, this form, and all others used under this clearance, will have both an OMB control number and an NPD 1420 control number that also restricts access to NASA internal users only.

¹³ This clearance package is to obtain permission to develop instruments to be used in testing that will be approved by OMB first for inclusion under this clearance prior to testing.

however your identity will not be disclosed. Presentations and manuscripts typically contain participants’ quotes, but participants are never identified by name. Your involvement in the development of this instrument is entirely voluntary and you have the right to discontinue participation at any time.

Contact Persons

If you have any additional questions concerning the research, this informed consent, or confidentiality of responses, please contact Richard L. Gilmore Jr., Evaluation Manager, at richard.l.gilmore@nasa.gov or call (216)433-5493.

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I have read and understand the contents of this study information and informed consent form and have been encouraged to ask questions. I have received answers to the questions I have asked. I give my consent to participate freely in this research. I have signed and retained a copy of the information and consent form for my records and future reference. I have signed and submitted this information and consent form for the researcher’s records.

Participant's signature Date

Participant's printed name

Researcher's signature

Privacy Notice: This is not a government application, the application is controlled and operated by a third party. NASA’s Web Privacy Policy does not apply to this application. NASA will not maintain, use, or share Personally Identifiable Information (PII) that becomes available through the use of this third-party application unless expressly stated and consent is obtained from the user. For additional information on NASA’s Third-Party Privacy Notice please go to http://www.nasa.gov/about/highlights/HP_Privacy.html.

Paperwork Reduction Act Statement: This information collection meets the requirements of 44 U.S.C. §3507, as amended by section 2 of the Paperwork Reduction Act of 1995. You do not need to answer these questions unless we display a valid Office of Management and Budget (OMB) control number. The OMB control number for this collection is 2700-0159 and expires 06/30/2021. We estimate that it will take 15 minutes to read the instructions and answer the questions. Send only comments relating to this time estimate to: richard.l.gilmore@nasa.gov.