Att 5

Flesch-Kincaid Reading Level 8.9

Urine Testing for Boron

Coronet Industries Plant City, Florida Exposure Investigation

Adult Informed Consent and Parental/Guardian Permission Form

Purpose

The Florida Department of Health (Florida DOH) and the Agency for Toxic Substances and Disease Registry (ATSDR) are doing an exposure investigation to learn if you or your family are being exposed to high amounts of boron in your water. Recently, ATSDR and Florida DOH reviewed the results of the well water sampling of residents living near Coronet Industries, Inc. Results showed levels of boron in some of the wells which were above the Florida DOH health advisory level. Currently, we do not know if you are being exposed to boron by drinking water from your well. Therefore, we would like to test the urine we have already collected on August 21, 2003 for boron.

We will be offering free urine testing for all people who live in your home and might be exposed to boron.

Procedures

Urine testing. Urine samples were collected on August 21,2003 as part of an exposure investigation to learn if you or your family are being exposed to high amounts of arsenic, cadmium, lead, fluoride, or uranium from your well water. We have enough of you and your family`s urine to also test for boron. We have not received any results on your urine sample so far.

Survey

A survey was conducted by ATSDR and the Florida DOH on August 20,2003 when we collected your urine sample. This survey was done to help us better understand your results.

Benefits

I will benefit from being tested because I will find out if I (or my child/ward) have been exposed to boron at levels higher than found usually in people who live in the United States. If the test show high levels of boron, I will get information on how to lower my current exposure to boron.

Risks

I know that ATSDR and the Florida DOH will not be able to tell me if my family or I were exposed to boron in the past. This is because the urine tests only measure boron in the last couple of days.

Participation

I know that my family and I are free to join this testing . I know also that my family and I will not lose any benefits if we decide not to be tested. Even if I agree to be part of this testing and I sign this form, I or my child/ward can stop being part of this testing at any time without penalty or loss of benefits. I know and agree that ATSDR cannot offer medical treatment based on the test results. I know that I must sign this form for me or my family to join the testing.

Results

I know that ATSDR will try to give me the test results for my family and me in writing within 3 months. However, delays might occur. If ATSDR finds high levels of boron in my urine, they will tell me my results as soon as they learn them. In some cases, ATSDR may ask me to repeat the urine testing. I will be given the actual test results for my family along with information on what the results mean. If my results show a high level of boron, I know that I should tell my personal doctor.

Confidentiality/Privacy

Information collected in this test will be kept private to the extent permitted by state and federal laws. Any reports written using this information will give only group information. The reports will not identify my family or me by name. If I participate, any forms with my name or address will be kept in locked cabinets at ATSDR or in password-protected computer files. If I say it is OK, my test results may be given to other federal, state, and local public health and environmental agencies. These agencies must also protect this information.

Contact

If I have any questions or I feel my family or I have been harmed by this investigation, I can call Dr. Mike Patterson of ATSDR toll-free at 1-888-442-8737.

Consent

All of my questions about this exposure investigation have been answered. I agree to be a part of this investigation.

I____________________________ (print), agree to urine sampling and completing questionnaires for:

(___) Myself

(___) My child/ward, _____________________________________, age ______

(___) My child/ward, _____________________________________, age ______

(___) My child/ward, _____________________________________, age ______

Please check one:

G I agree to allow ATSDR to share my household’s test results with other federal, state, and local agencies.

G I do NOT agree to allow ATSDR to share my household’s test results with other federal, state, and local agencies.

Signature: ___________________________________________ Date: ________________

Address: ____________________________________________

____________________________________________

____________________________________________

Phone #: _____________________

Assent Form for Children

(7 - 17 years of age)

A statement to be read to children in the presence of the parent/guardian:

“We want to find out if you have been exposed to a chemical called boron. Boron is a chemical that you cannot see but may cause illness. To know if you have boron in your body, we would like to check the urine we already have collected for boron. It is very safe, and your mom/dad/guardian has said that it would be okay for you to do this.”

“Do you have any questions? May we check your urine for boron?”

The above information has been read to me and I want to be a part of this testing.

Name of Child: ___________________ Signature of Child ______________________Age____

Name of Child: ___________________ Signature of Child ______________________Age____

Name of Child: ___________________ Signature of Child ______________________Age____

Name of Child: ___________________ Signature of Child ______________________Age ____

Name of Child: ___________________ Signature of Child ______________________Age____

Date: ______________