Attachment 5-Consent form

Consent Form

2030 Census: Administrative Data Cognitive Interview

The Census Bureau routinely conducts research and collects information from people across the United States.

____________ consents to take part in [a focus group/an interview] regarding your opinions on topics related to the collection of information in the 2030 decennial census. In order to have a complete record of all comments, the [focus group discussion/interview] will be audio-recorded. The Census Bureau plans to use the recordings to assist in the analysis of the information gathered during the [group discussions/interviews]. Staff directly involved in the project will have access to the recordings. Participation is voluntary and answers will remain strictly confidential. You may withdraw from the discussion at any time. Your participation and any comments you make will be kept confidential. Comments from all participants will be combined in a summary report that will not identify any individual. The interview is expected to take 60 minutes. You will receive $40 as a token of appreciation for your participation.

This voluntary survey is being conducted under the authority of Title 13 U.S. Code, Sections 141 and 182. Federal law requires that your answers are kept confidential (Title 13, U.S. Code, Section 9) and protects your privacy under the Privacy Act (Title 5 U.S. Code, Section 552a).  Per the Federal Cybersecurity Enhancement Act of 2015, your data are protected from cybersecurity risks through screening of the systems that transmit your data. The purpose of this survey is to improve future censuses and Census Bureau surveys. Routine uses of these data are limited to those identified in the Privacy Act System of Record Notice titled “COMMERCE/CENSUS-5, Decennial Census Programs.”Furnishing this information is voluntary; however, failure to do so will limit the Census Bureau’s ability to gather information used in the development of survey instruments, and other communication materials in order to produce materials that are clear and easy for people to understand.Personally Identifiable Information collected includes name, telephone/cellular phone number, DOB or age, email address, race, or ethnicity. The information provided to us may be shared with other Census Bureau staff, contractors and those who have a need to know for work-related purposes and are sworn to uphold the confidentiality of the data. The Census Bureau can use your responses only to produce statistics and is not permitted to publicly release your responses in a way that could identify you, your business, organization, or institution. 

We estimate that completing these screening questions will take 10 minutes on average. This information collection has been approved by the Office of Management and Budget (OMB). You can validate that this survey is a legitimate using the Office of Management and Budget's approval number 0607-0725, which expires 12/31/2025.  We are required to tell you this number to conduct this survey. Send comments regarding this estimate or any other aspect of this survey, including suggestions for reducing the time it takes to complete this survey to adrm.pra@census.gov.

I have agreed to participate in this Census Bureau research study, and I give permission for my recording to be used for the purposes stated above.

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Participant's Signature Researcher's Signature P ID

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Participant’s Printed Name Researcher’s Printed Name

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