Consent Form

Consent to Participate in Research about Group Quarters

Purpose. The purpose of this study is to get feedback on questions that we will use to collect information about health care facilities for the 2030 Census of Group Quarters, which is conducted by the U.S. Census Bureau as part of the Decennial Population Census.

Procedures. If you agree to participate, we will ask you to review a questionnaire and provide your feedback on the questions we ask. We will also ask you general questions about your facility and the services it provides. The interview should take 60 minutes or less on average.

Confidentiality. This study is being conducted under the authority of 13 U.S.C. Sections 141, and 193. Federal law requires that your answers are kept confidential (13 U.S.C. Section 9), and protects your privacy under the Privacy Act (5 U.S.C. Section 552a). Only research staff from the U.S. Census Bureau will know your answers and/or comments from the interview.  

 

Possible Risks and Discomforts. We do not anticipate any risks or discomforts as a result of participating in this study. However, should you feel uncomfortable with any question asked you may skip the question or stop the interview at any time.

 

Voluntary Participation. Your participation is completely voluntary.

 

Audio Recording. With your permission, we would like to record this interview. The interview will be audio-recorded to make sure we don’t miss anything that you say, and to help us write a report summarizing the results of the interviews. Direct quotes may be used in reports or in research presentations, but your name will never be used in any reports or presentations. If you do not wish to be recorded you may still participate in the interview.

I have read and understand the statements above. I consent to participate in this study.

Use your mouse or finger to sign your name in the box below.

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