MySSAccess Participant Screener and Consent Form

PARTICIPANT SCREENER

Online Authentication System: End to End Testing

General Information/Recruiting Specifications— General Public

• Recruit 20 participants (15 will be tested). Recruit seven participants from each of the following age groups: 26-45 and 46-59. Recruit two participants from each of the following age groups: 21-25, 60-65, and 66 and above.

• All participants MUST have a Social Security number

• No participant can currently be employed by the Federal government (including SSA)

• All participants must use the Internet to conduct online banking or shopping themselves, without assistance of others.

• Usability Testing will be held on <Date> at 10:00am, 1:00pm, and 3:30pm. Usability Testing will be held on <Date> at 1:00pm and 3:30pm. Each session is 2 hours long. Three participants will be tested in each session. A fourth person will be recruited and need to remain at the facility during the testing.

• Note: We are looking for participants who are comfortable reading and writing in English. The entire session will be conducted in English and you will be asked to read material written in English.

Hello, my name is _______ and I am calling on behalf of ICF Macro. We are conducting study for the Social Security Administration (SSA) to gather the public’s opinions about a new way for individuals to conduct business online with Social Security.

The study will consist of a one-on-one interview followed by a short focus group session on <date> in Catonsville, Maryland. We will ask you to use a computer to complete certain tasks. The session will last about 2 hours. If you are eligible and decide to participate, you will receive a stipend of $100. The interview will be strictly for research, and all of your comments will be confidential. If you are interested in participating, I need to ask you a few questions to see if you fit the demographics we are looking for.

1. Are you currently employed by a Federal government agency?

( ) No (Continue)

( ) Yes (Terminate)

2. Is English your native language?

( ) Yes (Skip to Q4)

( ) No (Judge participant’s comfort with English during the screening. If unsure, ask the next question)

Ask if Q2=No

3. Do you read books and websites in English?

( ) Yes (Continue. Terminate at any time if you feel that the participant will have difficulty communicating in English.)

( ) No (Terminate)

4. Approximately how many hours per week do you use a computer?

( ) Less than 2 hours each week (Terminate)

( ) 2 to 9 hours a week (Continue)

( ) 10 to 19 hours a week (Continue)

( ) 20 hours or more a week (Continue)

5. Approximately how many hours a week do you spend on the Internet?

( ) Less than 2 hours each week (Terminate)

( ) 2 to 9 hours a week (Continue)

( ) 10 to 19 hours a week (Continue)

( ) 20 hours or more a week (Continue)

6. Do you use the internet without assistance to bank or shop online?

Clarification: This means you do not need another person to fill out an online form or complete a shopping transaction for you. Banking online refers to any type of account they have that they manage online (checking, saving, retirement)

( ) Yes (Continue)

( ) No (Terminate)

7. To which age group do you belong?

( ) under 21 (Terminate)

( ) 21-25 Recruit 2 individuals

( ) 26-45 Recruit 7 individuals

( ) 46-59 Recruit 7 individuals

( ) 60-65 Recruit 2 individuals

( ) 66 and above Recruit 2 individuals

8. Do you have a Social Security number?

( ) Yes (Continue)

( ) No (Terminate)

9. Have you recently moved or changed your mailing address?

( ) Yes (Terminate)

( ) No (Continue)

10. Have you recently changed your last name?

( ) Yes (Terminate)

( ) No (Continue)

The following questions are optional. You may choose not to answer any or all of them. This will have no bearing on your eligibility to participate in this study.

11. What is your gender?

( ) Female

( ) Male

12. Please identify your highest completed level of education.

( ) Some High School

( ) High School Diploma/GED

( ) Some College or Associate’s Degree

( ) Bachelor’s Degree

( ) Graduate or Professional Degree (M.D., J.D.)

13. Please tell us the race or ethnic origin you identify with. (1 or more responses are OK)

( ) American Indian or Alaska Native

( ) African American or Black

( ) Asian

( ) Hispanic or Latino

( ) Native Hawaiian or Pacific Islander

( ) White (Caucasian)

INVITATION

Thank you for completing this survey. Based on your responses, we would like to invite you to take part in this study. This study is being done on a new Social Security website. During this study, the system will need to verify some information about you. You will need to provide your full name, social security number, date of birth, mailing address, and a valid email address. You will also be required to provide answers to three or four questions for which only you are likely to know the answers. These questions will help ensure that only you can create an account in your name. The system used in the study is built in accordance with the Privacy Act Statement and none of the observers present will be able to see the information you enter online. Your participation today will not change your current relationship with Social Security. At the conclusion of this study, you may have a User ID to use in conducting business online with Social Security.

Are you able to participate on <date/time>? You will be paid <dollar amount> for participating.

14. Are you willing to participate?

( ) Yes (Continue)

( ) No (Terminate)

I’m glad that you will be able to join us! At this point, I need to collect some contact information from you.

(Note: This information is required only as a part of this study. Your information is kept strictly confidential to the extent permitted by law. Your phone number is required only for a reminder call that will be made prior to the start of the research study).

First name:

Last name:

Email:

Daytime phone:

Evening phone:

Mailing Address:

City:

State:

Zip Code:

We are only inviting a few people, so it is very important that you notify us as soon as possible if for some reason you are unable to participate. Please call or email <contact and phone, email> if this should happen. Please be advised that you will need to remember your social security number in order to participate in this study. We look forward to having you participate on <date>.

Thank you for your time and we will be in touch again the day before the session.

TERMINATE TEXT

Thank you very much for you time, and thank you for answering our questions. Unfortunately, based on the requirements, we cannot extend you an invitation. Perhaps we can include you in a future research session. Have a good [day/evening].

INFORMED CONSENT FORM

What We’re Doing

We are evaluating some new web site pages for the Social Security Administration. We are creating a secure registration process that will allow members of the public to request some often-needed services online. We want to ensure that this site will be as easy to use as possible. We are not in any way evaluating you.

How We’re Doing It

As you use the designed screens for this web site we will be collecting information on paper and electronically about the way that you use the screens to accomplish your goal. We will also ask you to tell us what you are thinking. We will also ask you some background questions to get more information about how you might use the Internet to do your Social Security business in the future. We will also ask you to participate in discussions.

We expect the evaluation will take approximately one and a half hours.

Some of these evaluations may be videotaped or audio recorded.

Some of the people responsible for creating this site may also be observing the evaluation.

What Happens to the Information We Collect

Only persons associated with this web site evaluation will be permitted to view videotapes or any other information collected as part of the evaluation. We use the videotapes primarily to capture the time you spend completing the application. We may also analyze the videotapes to identify where design improvements might be made.

The results of this evaluation may be used in internal Social Security documents, but you will not be identified in these documents.

Risks

There are no known risks associated with this evaluation. Your Social Security benefits will not be affected in any way by your participation in this evaluation.

You Can Withdraw at Any Time

You can withdraw from the evaluation at any time for any reason. In addition, at the conclusion of the evaluation, you may see the information we have collected. If you decide to withdraw this information, please inform the evaluation monitor immediately. Otherwise, we might not be able to identify your information because of our efforts to ensure anonymity.

Voluntary Consent

By signing this form, you are saying that you have read this form. You are also saying that you understand the form and understand what we are asking you to do. The evaluation monitor should have answered any questions you have about this evaluation. If you have any questions later on, the person below should be able to answer them:

Ken Bertram 410-594-2033

By signing below, you are telling us that you agree to participate in this evaluation. You will receive a copy of this form.

SIGNATURE: _______________________________________________________

NAME: ____________________________________________________________

DATE: _____________

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