Adult Consent Form

Appendix F: Adult Consent Form

Consent Form for Individual Participants

Usability testing of the National Food Study 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 study that aims to better understand how people in the United States get their food. The study is expected to last between 60 and 120 minutes. 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 (Expiration date: 12/31/2025). This valid approval number legally certifies this information collection.

Privacy Notice

The U.S. Census Bureau is required by law to protect your information. The Census Bureau is not permitted to publicly release your statements in a way that could identify you. We are conducting this session under the authority U.S.C, Title 7 Section 2026 (a) (1) and section 3171. Federal law keeps your answers confidential (13 U.S.C., Section 9). Your voluntary response will be used to improve language and usability of the National Food Study online questionnaire.

Your privacy is protected by the Privacy Act (5 U.S.C., Section 552a). The information provided may be shared with other Census Bureau staff for the work-related purposes identified in this statement. Participating in this focus group implies consent for the purposes stated. The Census Bureau strictly adheres to the provisions of the Privacy Act.

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: __________