36C10B19Q0067-003.docx

VA Research Participation Consent

Session Description You are being asked to participate in a feedback session to give your opinion on a website created by the Department of Veterans Affairs. By participating in this feedback session, you will help the VA improve this website.

This feedback session will take about 1 hour. We'll ask you some questions and watch how you use the website. We'll also record your comments and actions using written notes, audio recording, and screen recording. If you don’t want us to record one of these things, you can say no. We won't use your name when we're presenting the results of this feedback session. We may use the recording in the future to help show others how to improve websites.

You may quit the session at any time. If you need a break, just tell the moderator. If you have questions, go ahead and ask them whenever you like.

Consent By initialing below and signing this form, I give my permission for the VA to use:

· Written notes of verbal statements (initial here ______)

· Recorded voice (initial here ______)

· Screen recording (initial here ______)

I understand that I may quit the session at any time. If I need a break at any time, I will tell the moderator. I agree to ask questions about the session if I don't understand something. If I have questions after the session is over, I can contact [name] at [email]@va.gov.

I expressly release the Department of Veterans Affairs from and against any and all claims, which I have or may have for invasion of privacy, defamation, or any other cause of action arising out of the production, distribution, display or publication of the results of the project, as the conditions described above are met.

By signing below, I indicate agreement with these terms above.