Consent Form

ASEC Cognitive Interview Participant Informed Consent Form

What is the purpose of this interview?

The U.S. Census Bureau is conducting interviews to help with the design and content about a portion of the Current Population Survey (CPS). This module, called the Annual Social and Economic Supplement (ASEC) is an important source of information about our nation on topics such as employment, health insurance, and income. It’s important that the questions make sense, are easy to answer, and that everyone understands the questions in the same way. You are one of about 60 people who are being asked to participate in these interviews. Findings from these interviews will be used to clarify survey questions and instructions on the survey.

What will happen if I take part in this interview?

If you agree to take part in this study, you will be asked to answer questions about your household, including yourself and other people that live with you. The interview will be conducted virtually by a staff member from RTI International or Research Support Services, who are doing this study for the U.S. Census Bureau.

We would also like to audio and video record the interview. Only the people who work on this study will review the recording. It will help us make sure we accurately capture your answers. If you don’t want to be recorded, that’s okay – you may still participate in the interview.

How much time is required to participate?

The interview will last approximately 90 minutes.

Do I have to take part in this interview?

No, participation in this interview is voluntary. You can stop the interview at any time, and you don’t have to answer a question if you don’t want to. You will not lose any rights you would normally have if you choose not to join this interview.

What are the possible risks and benefits from participating in this interview?

There are no direct benefits to you from doing this interview. Your involvement in this study will help us improve the questions for the Current Population Survey. There is no more than minimal risk in participating.

How will my privacy be protected?

By law, we are required to keep your answers confidential. The U.S. Census Bureau is conducting this study under the authority of 13 U.S.C. Sections 141, 182, and 193. Your privacy is protected by the Privacy Act of 1974 (5 U.S.C. Section 552a). Only research staff from the U.S. Census Bureau, RTI International, and Research Support Services will know your answers to interview questions. 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 or other members of your household.

This collection has been approved by the Office of Management and Budget (OMB). This eight-digit OMB approval number, 0607-0725, confirms this approval and expires on 12/31/2025. Without this approval, we could not conduct this study.

How will I be compensated?

You will receive $40.

What if I have questions about the interview?

If you have concerns or questions about the interview, you may contact RTI’s project director, Patty LeBaron, at 312-777-5204 or plebaron@rti.org.

- - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - -

Participant’s Agreement:

I have read the information provided above. I voluntarily agree to participate in this interview.

 I agree for this interview to be audio and video recorded.

 I do not agree for this interview to be audio and video recorded.

_______________________________________ _________________

Electronic Signature of Research Participant Date

_________________________________________

Typed Name of Research Participant

2