consent form

Consent Form

For Individual Participants

Qualitative Pretesting of the Census Mailing Materials and Online Questionnaire

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 surveys and questionnaires in order to obtain the best information possible.

You have volunteered to take part in a 90-minute study that has two purposes: 1) to improve the mailing materials that will be used for the decennial census and 2) to improve the usability of a version of the decennial census online instrument. If you have any questions about the burden estimate or any other aspects of the burden, you can contact adrm.pra@census.gov. In order to have a complete record of your comments, your session will be audio recorded and videotaped. Only staff directly involved in the research project will have access to the recordings. Your participation is voluntary and your answers will remain strictly confidential.

The OMB control number for this study is 0607-0725. This valid approval number legally certifies this information collection.

Privacy Act Statement

Authority for the collection of your personal information for the U.S. Census Bureau’s 2024 Census Test pretest is authorized under 5 U.S.C. § 301 and 13 U.S.C. §§ 141 and 193.

The purpose of collecting this information is to contact you electronically to notify you that it is time to participate in pretesting. Personal information collected includes your name, address, e-mail address, and cell phone number.

Disclosure of the information provided to us may be shared with other Census Bureau staff for the work-related purposes identified in this statement as permitted under the Privacy Act of 1974 (5 U.S.C. Section 552a). Disclosure of this information is also subject to the published routine uses as identified in the Privacy Act System of Record Notice COMMERCE/CENSUS-5, “Decennial Census Program”.

Furnishing this information is voluntary. However failure to provide this information may affect the quality of the Census Bureau’s testing for the 2024 Decennial Census.

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

Participant’s Name: ______________________________________

Participant's Signature: ____________________________________ Date: ­­­­­__________

Researcher’s Name: _____________________________________

Researcher's Signature: ___________________________________ Date: __________