Appendix C

Informed Consent and Link to Enter Survey

The Consumer Financial Protection Bureau (CFPB), a U.S. Federal government agency, has asked 

the Corporation for Enterprise Development (CFED) and the Center for Financial Security (CFS)

at the University of Wisconsin Madison, to develop surveys that may later be used to gather 

data on financial well-being and its drivers.

What is the purpose of this project?

The purpose of this project is to test financial well-being-related survey questions. As part of this 

project, you will be asked to answer a roughly 17 minute online survey asking you about your 

financial well-being and about your financial behavior and knowledge. Your answers will be 

used to test the use of these questions for later surveys.

Privacy and Confidentiality

You will be asked to provide no information which directly identifies you as part of your 

participation in this survey. Any directly-identifying information you have provided to Survey 

Sampling International (SSI) as part of your pre-existing agreement to participate in this and 

other surveys is available only to Survey Sampling International (SSI), not to the CFPB, and is 

subject to the terms and conditions of those existing agreements [This will link to SSI privacy 

policy]. Any answers you provide to the survey, including general demographic information such 

as age and race, will be kept confidential, except as otherwise required by law. Additionally, the 

Bureau will treat the information collected consistent with its confidentiality regulations at 12 

C.F.R. Part 1070, et seq. Your responses, but not any information that directly identifies you, will 

be combined with those of other survey respondents and shared for the purpose of analysis 

with members of the study team which includes CFED, CFS and the CFPB along with 

subcontractors and affiliates engaged in financial well-being-related research.

Among other things, the Dodd-Frank Act authorizes the CFPB to conduct research related to 

consumer financial behavior and education. 12 USC § 5493(b)(1); id. § 5493(d)(3)(B); id. 

5493(g)(3)(D).

Risks

There are few risks to you. This project involves you answering questions about your financial 

knowledge, behavior and well-being. We recognize that you might be uncomfortable answering 

some questions about finances or demographic information.

Right to Refuse or Withdraw

You may choose not to participate in the survey at any time. You may choose not to answer a 

question for whatever reason by selecting the ‘refuse to answer’ option. Participation is 

completely voluntary. Your incentive payment is, however, dependent on your completion of 

the survey and subject to the terms of your agreement with SSI.
Benefits

Sharing your thoughts and ideas will help us and the CFPB better understand how to measure

the financial well-being of American consumers like you.

Paperwork Reduction Act

According to the Paperwork Reduction Act of 1995, an agency may not conduct or sponsor, and 

a person is not required to respond to a collection of information unless it displays a valid OMB 

control number. The OMB control number for this collection is XXXX. It expires on XX/XX/XXXX. 

The time required to complete this information collection is estimated to average 17 minutes

per survey. The obligation to respond to this collection of information is voluntary. Comments 

regarding this collection of information, including the estimated response time, suggestions for 

improving the usefulness of the information, or suggestions for reducing the burden to respond 

to this collection should be submitted to Bureau at the Consumer Financial Protection Bureau 

(Attention: PRA Office), 1700 G Street NW, Washington, DC 20552, or by email to 

PRA@cfpb.gov.

Contact Information

If you have questions about your rights as a participant, you may contact Anita Drever at the 

Corporation for Enterprise Development at 202.207.0142 or adrever@cfed.org. 

If you consent to the survey, you may use the link below to begin. Selecting the link indicates

that you have read the above and agree to take part in this research.

Do you agree to the terms described above?

Yes : move forward 

No: exclude