Focus Group Consent Form

Appendix F: FOCUS GROUP CONSENT FORM

Form Approved

OMB No. XXXX-XXXX

Exp. Date XX/XX/XXXX

INFORMED CONSENT FORM

We ask that you take part in an information collection. This form describes the purpose, benefits, and risks of the information collection. It also describes your right to withdraw at any time. A member of the project staff will read through this form with you and discuss all the information if you like.

Why are you collecting this information?

We are collecting information to understand how people make decisions about how to respond to the U.S. census. The findings will inform the development of 2030 Census communication and data collection methods.

What do I need to know about this project?

Adults aged 18 and older are able to participate. If you choose to participate, the project team will tell you when your focus group meets. During the focus group, the moderator will ask you to share your thoughts and attitudes about the census. The focus group will last about 90 minutes. There are no costs associated with your participation. You do not have to answer any questions that you do not want to.

In accordance with the Paperwork Reduction Act of 1995, the federal government’s Office of Management and Budget (OMB) has approved the questions asked through this project. The OMB control number is XXXX-XXXX, which expires on [DATE]. Without this approval, we could not ask these questions.

Members of the project team may observe the focus group session. The observers will take notes and listen, but they will not bother you. You will only talk to the moderator and a small group of other participants.

What are the potential risks of being in the focus group?

There are minimal risks associated with this project. Breach of confidentiality or privacy is possible, but the risk is reduced because your responses are not linked to your name or other identifying information. Instead, we will use a code, and the project team agrees to protect your privacy and confidentiality. You do not have to answer any questions that you do not want to answer.

Does participating in this project provide any benefit?

There is no direct benefit to you in participating in this project. The information from the focus groups will help us decide what ideas and messages might be useful in educational outreach about the U.S. census, as well as how we ask census questions.

Will it cost me anything to participate in the project?

There are no costs to participate in the project. Participants in the focus groups will receive $75 for their participation.

Do I have to be in this project?

Your participation is voluntary, which means you can stop at any time.

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Who will see the results of this project or my information?

The research team will hear everything you say during the focus group. Only people working on the project see your information.

The focus group will be audio- and video-recorded and transcribed. By signing this form, you consent to being recorded during the focus group.

Your name and other personal information will not be linked to your responses.

All of the information we collect, including anything you say in the focus group, information collected during screening, audio files, video files, and transcripts will be stored on a password-protected computer or in locked cabinets that only the project team can access. After three years, all of the collected information will be destroyed by securely shredding documents or permanently deleting electronic information.

Results from this project may appear in professional journals or scientific conferences or shared with other project teams. No individual participants will be identified or linked to the results. We will not disclose your identity in any report or presentation.

What if I have questions about the project?

If you have questions or concerns about the project, you can contact Rodney Terry. You can reach her by email at Rodney.Terry@census.gov or by phone at 301-763-5475. You can ask questions about this consent form or the project at any time. This includes before you decide to start the project, at any time during the project, and after the project is complete. If you decide to start the project and then change your mind, you can stop participating at any time without penalty or loss of benefits.

Are my answers confidential?

Yes. The U.S. Census Bureau is required by law to protect your information (13 U.S.C. § 9 and

§ 214). The Census Bureau is not permitted to publicly release your responses in a way that could

identify you or your household.

Please mark a box and sign below. By signing this form, you have not waived any of your legal rights.

Yes, I agree to participate in this project. I have read, understand, and had time to consider all of the information above. My questions have been answered, and I have no further questions.

No, I do not agree to participate in this project. I have read, understand, and had time to consider all of the information above. My questions have been answered, and I have no further questions.

Signature Date

If you would like a copy of this form for your records, please ask the project team.

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