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Copy this template, save a copy to your project folder & modify as needed. When onsite, have the consent form on hand to sign.

Participant Consent Form with Incentive

I voluntarily agree to participate in a research study performed by ____________________, of the City of Austin. I understand that this study is being conducted in order to uncover opportunities for the design and improvement of city services.

I understand the research study will be documented and the data used by the City of Austin as evidence for design. In support of transparency in government practice, I understand that any identifiable information in regards to my name and/or company will be anonymized as reasonably as possible, but my image may be used to share research methods across programs and publications. I also understand that my name, company, and/or image will become public record. The Texas Public Information Act gives people the right to access public records.

I grant my permission for this interview to be documented through:

  • written notes
  • photos
  • audio recording
  • video recording

I understand that I will receive the following incentive for my participation in an interview: ____________________.

I understand that any identifiable information in regards to my name, picture, and/or company will be anonymized as reasonably as possible, but may be used to share research methods across programs and publications.

Printed Name Signed Name Date

I have received a incentive of ____________________________ for my participation in this research study.

________________________________________________________________

Printed Name Signed Name Date

Be sure to collect the following from the participant in order to track the compensation:

Gift cards/ bus passes for residents may be purchased and distributed as part of a critical City program (for example, incentive cards for public immunization programs). Departments issuing cards to residents must:

  1. Get approval from your Department's Supervisory and Management staff
  2. Obtain approval by completing this form (this is CTM's Form; please obtain equivalent from your department) and obtaining Department Director's signature or Assistant Director's signature prior to purchase (CTM staff please get CTM Chief Information Officer signature or the signature of a Deputy CIO)
  3. A signed approval must be presented to your Department's Financial Staff with receipts.
  4. Submit a Purchase Request in Works, regardless of the total dollar amount of gift cards requested.
  5. Create and record the dollar amount and recipient’s name for each gift card distributed.
  6. See the log at the end of the approval form for the example
  7. File the log (with confidential data redacted), the receipt, any other supporting documentation, and Payable Allocation report in the Department’s Pro Card files.
  8. Electronically attach all related transactions in Works and close the Purchase Request

Example Log:

Card/Bus Pass Number Date Issued Dollar Amount of card Name of Participant

1

2

3