Att M - Registrant Consent

Attachment M. Informed consent for registrants only. (ATSDR Letterhead)

Reading level: 8.17

ATSDR Health Survey of those who lived or worked at Camp Lejeune or Camp Pendleton in 1987 or before

Introduction and Purpose

The Agency for Toxic Substances and Disease Registry (ATSDR) is doing a health survey of thosepersons who lived or residedworked at Camp Lejeune or Camp Pendleton in 19871985 or before. beingATSDR The ATSDR Health Survey of Marine Corps Personnel and Civilians is conductingfunded by the U.S. Navy and the Marine Corps. ATSDR is doing this survey to learn more about the health effects of workplace and environmental exposure to chemicals. We are inviting people who were exposed to chemicals, as well as those who were unexposed, to take part in the exposures. The survey asks questions about when and where you lived or worked at Camp Lejeune or Camp Pendleton. It also asks about your work history and your health.

The survey will ask questions about:

when and where you lived at Camp Lejeune or Camp Pendleton

• your health

• work history, and

• smoking and drinking habits.

• The Navy and the Marine Corps are funding this survey. The authority for collecting this information, including your Social Security Number, is the National Defense Authorization Act for Fiscal Year 2008.

• Procedures

If you agree to participate in this health surveytake part, please read and sign this consent form and complete the enclosed survey. The completed survey should be mailed to Westat, a contractor for ATSDR. Please mail it back in the envelope provided.

You have the right to refuse to following survey. If you prefer, you can provide your consent on-line and answer any question or refuse to complete the survey.

2. Other than completing the survey, there will be no direct involvement with survey participants. at www.xxx.com. The survey should take about 45 minutes to complete.

3. All information will be kept private to the extent permitted by law. Data that identifies you or where you live will not be included in any report.

Risks and Benefits

This health survey involves only data collectionData are collected through a mail questionnaire or over the internet with minimal risk to participants. There will be no lab testing or medical procedures required in this survey.

Some of the questions are of a personal nature, like questions about your health. Answering the survey is voluntary. If you choose not to participatetake part, there will be no penalty. You will not lose any benefits if you decide not to continue.

participate. There are no direct benefits from participating in this survey. However, taking part in this survey will help us learn more about ways to improve health and prevent disease in the future..

Confidentiality

All answers you give will be kept private to the extent permitted by law. YouWe do not plan to share your information with anyone other than ATSDR staff and its contractors. Data that identify you or where you live will not be identified by nameincluded in any reports from this surveyreport. All information from the surveys will be kept in a locked file. Data will be safeguarded by storing the data separatestored separately from any personal identifiers.

If you complete the survey on-line, your privacy will be maintained to the degree permitted by the technology used. Security measures will be taken to protect data submitted over the internet. These include Secure Socket Layer (SSL) encryption and password-controlled servers with limited access.

The authority for collecting your social security number (SSN) is the National Defense Authorization Act for Fiscal Year 2008. Your SSN will be kept private. We do not plan to share this information with anyone other than ATSDR staff. We will use your SSN for identity verification purposes

If you have any questions about this survey, please contact the ATSDR Health Survey HotlineInformation Line at xxx-xxx-xxxx. For questions about your rights as a survey participant,  please contact CDC’s Human Research Protection Office at 1-800-584-8814.  Please leave a brief message with your name and phone number, and mention that you are calling about CDC protocol #5536.   Someone will return your call the Associate Administrator for Science, ATSDR at xxx-xxx-xxxx.as soon as possible.

Participant Consent

I have read or have had read to me the description of the ATSDR Health Survey. of Marine Corps Personnel and Civilians. I have been informed of the risks and benefits of the survey.

I understand that I do not have to take part in this survey. If I choose not to participate there will be no penalty.

My rights as a survey participant have been explained to me. I voluntarily agree to take part in this survey.

The purpose of the survey and how it is being done have been explained to me. I understand that I have the right to refuse to answer any question or refuse to complete the survey. I voluntarily agree to take part in this survey.

If completing the paper survey: An extra copy of the consent form has been enclosed for my records. I will mail the signed consent form back in the envelope provided.

___________________________________________________

Printed Name

____________________________________________________

Signature

____________________________________________________

Your name (please print)

____________________________________________________

Your signature

____________________________________________________

Date

If completing the survey on the internet: I can chooseI agree to print out a copy of the consent form for my records.potentially being re-contacted by ATSDR regarding participation in future studies about Camp Lejeune. I understand that by clicking the “I agree” button, I am agreeing to take partbe contacted in the survey.future is voluntary.

□ Yes I agree

□ No I do not agree

____________________________________________________

Your name (please print)

____________________________________________________

Your signature

____________________________________________________

Date

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