Attach 4A_Buccal Script North Carolina

OMB NO.: 0925-0406

EXPIRATION DATE: 10/31/2011

Attachment 4A:

Buccal Cell Collection Script and Consent for North Carolina Respondents

VERBAL CONSENT FOR BUCCAL CELL COLLECTION

(Interviewer’s Script)

Public reporting burden for this collection of information is estimated to average twenty-five minutes per response, including the time for reviewing instructions, searching existing data sources, gathering and maintaining the data needed, and completing and reviewing the collection of information.  An agency may not conduct or sponsor, and a person is not required to respond to, a collection of information unless it displays a currently valid OMB control number.  Send comments regarding this burden estimate or any other aspect of this collection of information, including suggestions for reducing this burden, to: NIH, Project Clearance Branch, 6705 Rockledge Drive, MSC 7974, Bethesda, MD 20892-7974, ATTN: PRA (0925-0406).  Do not return the completed form to this address.

Thank you for your participation in the Agricultural Health Study. We appreciate your help and would like to make an additional request. This request is voluntary and will provide very important information to the study. We would like to obtain a sample of loose cells from your mouth. This is called a buccal cell sample. This only takes a few minutes of your time, and is done simply by swishing mouthwash in your mouth and then expelling it into a container. Everything you need to collect the sample—including mouthwash, container, and complete instructions—will be mailed to you. A consent form will also be included in the kit, as well as materials for mailing the sample back to us. We will also enclose $5 for your time and effort in collecting and mailing the sample. As soon as we receive the sample, the cells will be put in a freezer for long-term storage and will be used for later laboratory analysis. Would you be willing to participate in the buccal cell collection?

(IF YES) >> Thank you. We will mail the buccal cell kit to you within the next few days along with the $5. Please read the instructions that are included carefully. If possible, we would like to ask you to complete this activity and mail it out as soon as you can. Also, don’t forget to sign and return the consent form along with the buccal cell sample. Thank you for your participation.

(IF NO)>> Do you have any questions or concerns about the buccal cell collection that I could answer for you? (ANSWER ANY QUESTIONS AND RECORD REPLY)

(IF R STILL REFUSES)>> Thank you for your time and your past participation.