Cross Walk - Table of Changes

Change Request for OMB #0923-0052

Cross-walk from the approved forms to the requested new forms and justifications

Approved Form

New Form

Justification

Eligibility Screening Survey

Att8a. Bhutanese and Burmese

Att8e. Subsistence Anglers

Eligibility Screening Survey

Att8a. Bhutanese and Burmese

Att8e. Subsistence Anglers

Att8a- 7. In the past 12 months, which of the following bodies of water did you fish from?

Att8e- 6. In the past 12 months, which of the following bodies of water did you fish from?

Att8e- 7. In the past 12 months, how many times did you eat fish caught in the bodies of water listed in #7?

Att8a- 7. In the past 12 months, which of the following bodies of water did you fish or eat fish from?

Att8e- 6. In the past 12 months, which of the following bodies of water did you fish or eat fish from?

Att8e- 7. In the past 12 months, how many times did you eat fish caught in the bodies of water listed in #6?

To capture bodies of water with reference to consumption of locally caught fish

Informed Consent Form

Att8b. Bhutanese and Burmese

Att8f. Subsistence Anglers

Informed Consent Form

Att8b. Bhutanese and Burmese

Att8f. Subsistence Anglers

Overview

The New York State Department of Health (NYS DOH) in cooperation with the Agency for Toxic Substances and Disease Registry (ATSDR) invite you to be in a project to measure pollutants in people who eat fish from Lake Ontario and tributaries; including Seneca River, Oswego River and Onondaga Lake.

Overview

The New York State Department of Health (NYS DOH) in cooperation with the Agency for Toxic Substances and Disease Registry (ATSDR) invite you to be in a project to measure pollutants in people who eat fish from Onondaga Lake and its tributaries, Seneca River, Oswego River and Lake Ontario.

The target populations live in close proximity to Onondaga Lake and using Onondage Lake as the primary reference is more meaningful for this audience.

What is the purpose of this project?

The purpose is to measure the levels of contaminants in people who eat fish caught from New York Great Lakes and rivers. The areas of interest are Lake Ontario and tributaries; including Seneca River, Oswego River and Onondaga Lake.

What is the purpose of this project?

The purpose is to measure the levels of contaminants in people who eat fish caught from New York Great Lakes and rivers. The areas of interest are Onondaga Lake and its tributaries, Seneca River, Oswego River and Lake Ontario.

Same justification as listed above

Are there any risks or discomforts to you if you decide to be in this project?

There are no risks from giving urine or having your weight, height, and waist measured.

Are there any risks or discomforts to you if you decide to be in this project?

There are no risks from giving urine or having your weight and height measured.

Correction as waist circumference measurement in not part of the protocol

What is the cost to you and what will you receive?

The only cost to you for being in our project is your time and effort to take part. We will give you $75 as a thank you for your participation if you complete all parts of the project visit.  If you are unable to complete all activities we will give you an amount based on the activities you do complete. You can use the gift card at most stores or for online shopping.

What is the cost to you and what will you receive?

The only cost to you for being in our project is your time and effort to take part. We will give you a $75 gift card as a thank you for your participation.

Correction to reflect change to a consistent , not staged $75 thank you in response to OMB comments

What should you do after reading this information?

1. I have read the above information about the project Biomonitoring of persons from Burma, Bhutan or Nepal living near New York State’s Great Lakes Basin. I have been allowed to ask questions and I had all my questions answered. I have been given a copy of this consent form. I would like to participate in the project.

(Check one box.)

 Yes  Go to #2.

 No

What should you do after reading this information?

I have read the above information about the Healthy Fishing Community Project in Syracuse, NY project. I have been allowed to ask questions and I had all my questions answered. I have been given a copy of this consent form.

If you could not read any of the translated consent forms: Signing this document means that the project, including all the above information, has been described to you orally, and that you voluntarily agree to participate. You have been allowed to ask questions and had all your questions answered. You have been given a copy of this consent form.

2. I would like to participate in the project.

(Check one box.)

 Yes  Go to #2.

 No

Project name per Advisory Committee for simplified local reference

Script added to accommodate oral consent for prospective participants who cannot read any of the consent forms

As presented in Supporting Statement A, page 16 section Opportunities to Consent to Sharing and Submission of Information: Any respondent indicating difficulty with reading will have the consent document read to him or her by the interviewer or an interpreter trained in appropriate Burmese or Bhutan dialects or Spanish language.

I read this consent form to the prospective participant in a language which he/she understands. The prospective participant was given a chance to ask questions, appeared to accept the answers, and signed to enroll in the study.

_______________________________________________

Signature of interpreter/ person obtaining consent Date

Script and signature added to document if the consent form was read to a prospective participant who cannot read any of the consent forms

Biomonitoring Interview Questionnaire

Att8c. Bhutanese and Burmese

Att8g. Subsistence Anglers

Biomonitoring Interview Questionnaire

Att8c. Bhutanese and Burmese

Att8g. Subsistence Anglers

Att8c. Bhutanese and Burmese

Script: We would like to give you the results of the blood and urine testing. When we receive the results, someone will help explain them to you.

7. Do you want your blood and urine results sent to your doctor or clinic?

___ Yes  go to #8

___ No  go to #9

___ Don’t have a doctor/clinic Go to *script and ask #7 again, or go to #9.

___ Don’t know  Go to *script and ask #7 again, or go to #9.

___ Refused

7. What is your doctor or clinic’s name, telephone number, and address?

Name of doctor or clinic: ______________________________

Telephone number: _________________

Address: ___________________________________________

*Use this script if participant does not provide physician’s name or does not have a physician/clinic.

If you do not want the results sent to your doctor or you don’t have one, the results will be sent to a doctor at the New York State Department of Health. When we receive the results, someone will help explain them to you, and the doctor at the Department of Health can answer any questions you have.

Att8g. Subsistence Anglers

6. If you want your blood and urine test results sent to your doctor, what is his/her name, phone number, and address?

Name of doctor: ______________________________

Telephone number: _________________

Address: _____________________________________________________________

*Script (if participation does not provide physician’s name):

If you do not want the results sent to your physician or you don’t have one, the results will be sent to a physician at the New York State Department of Health.

Att8c. Bhutanese and Burmese

Script: We would like to give you the results of the blood and urine testing. When you receive the results, someone will help explain them to you.

7. Do you want your blood and urine results sent to your doctor or clinic?

___ Yes  go to #8

___ No  go to #9

___ Don’t have a doctor/clinic Go to #9.

___ Don’t know  Go to #9.

___ Refused

7. What is your doctor or clinic’s name, telephone number, and address?

Name of doctor or clinic: ______________________________

Telephone number: _________________

Address: ___________________________________________

Att8g. Subsistence Anglers

6. If you want your blood and urine test results sent to your doctor, what is his/her name, phone number, and address?

Name of doctor: ______________________________

Telephone number: _________________

Address: _____________________________________________________________

Correction from “we” to “you”

and

deletion of script at the bottom. Participants are provided contact information on the consent form should they have any questions.

Deletion of script at the bottom. Participants are provided contact information on the consent form should they have any questions.

Att8c. Bhutanese and Burmese only

27. Did you live in any other countries?

___ Yes  go to #28

___ No  go to #29

___ Don’t know  go to #29

___ Refused  go to #29

27. Did you live in any other countries, excluding the countries where you lived in a refugee camp?

___ Yes  go to #28

___ No  go to #29

___ Don’t know  go to #29

___ Refused  go to #29

More precise wording to capture response in reference to having lived in countries not part of the participant’s refugee experience.

Att8c. Bhutanese and Burmese only

37. Which of the following fish caught from nearby waters have you eaten in the past 12 months? SHOW POSTER with pictures of fish ALONG with 15” fish model (Check All that Apply.)

Att8c. Bhutanese and Burmese only

37. Which of the following fish caught from nearby waters have you eaten in the past 12 months? SHOW POSTER with pictures of fish ALONG with 15” fish model (Check All that Apply.)

___ Alewife ___ Gizzard shad	___ Rudd ___ Golden shiner ___ Emerald shiner ___ Spot fin shiner	___ Short head redhorse ___ Greater redhorse ___ Silver redhorse
___ Round goby ___ Blunt-nose minnow ___ Fathead minnow ___ Long nose dace	___ Muskellunge/ Tiger muskie ___ Northern pike ___ Chain pickerel ___ Bowfin
Other (specify): __________________ Other (specify): __________________ Other (specify): __________________ Other (specify): __________________	___ Common carp ___ Long nose gar ___ Goldfish ___ Green sunfish ___ Northern hog sucker ___ White sucker ___ Channel catfish ___ Brown bullhead ___ Yellow bullhead ___ Black bullhead

Several fish species were inadvertently omitted in the refugee questionnaire. These species are included in the subsistence angler

Att8c. Bhutanese and Burmese only

44. What kinds of fish from nearby waters is the fish paste made from?

SHOW POSTER with pictures of fish ALONG with 15” fish model (Check All that Apply.)

Att8c. Bhutanese and Burmese only

44. What kinds of fish from nearby waters is the fish paste made from?

SHOW POSTER with pictures of fish ALONG with 15” fish model (Check All that Apply.)

Revised fish species table

The table of fish species is revised to match the table presented in question #37.

Att8c. Bhutanese and Burmese only

48. How many years did you eat [fish/shellfish]?

___ years

___ Don’t know

___ Refused

Att8c. Bhutanese and Burmese only

48. How many years did you eat [fish/shellfish]?

A Response table is added to capture responses for each fish/shellfish listed in question #47. FORMATTING CHANGE ONLY

Question 48 is asked for EACH fish answered in question 47 (Grouper, Shark, Swordfish, Salmon-including canned, Tuna-not canned, Tuna-canned, Shrimp, Snails, and Mussels)

Att8g. Subsistence Anglers only

45. Over your lifetime, how many years have you eaten any of these fish bought at a store or supermarket? SHOW CARD.

___ years

___ Don’t know

___ Refused

Att8g. Subsistence Anglers only

45. Over your lifetime, how many years have you eaten any of these fish bought at a store or supermarket? SHOW CARD.

A Response table is added to capture responses for each fish/shellfish listed in question #44. FORMATTING CHANGE ONLY

Question 45 is asked for EACH fish answered in question 44 (Grouper, Shark, Swordfish, Salmon-including canned, Tuna-not canned, Tuna-canned)

Att8c. Bhutanese and Burmese only

45. In the past year, how many times did you eat [fish/shellfish]?

___ times per (circle one) week month year

___ Don’t know

___ Refused

Att8c. Bhutanese and Burmese only

49. In the past year, how many times did you eat [fish/shellfish]?

A Response table is added to capture responses for each fish/shellfish listed in question #47. FORMATTING CHANGE ONLY

Question 49 is asked for EACH fish answered in question 47 (Grouper, Shark, Swordfish, Salmon-including canned, Tuna-not canned, Tuna-canned, Shrimp, Snails, and Mussels

Att8c. Bhutanese and Burmese only

Numbering on questionnaire- 50-78

Att8c. Bhutanese and Burmese only

Numbering on questionnaire- 50-78

ALTHOUGH INDICATED IN TRACKED CHANGES NO NUMBERING CHNAGES ARE MADE. I cannot get this to stop happening.

Microsoft Word Track Changes Function is indicating numbering changes where there are none. The numbering in the new ‘clean’ document and original OMB approved document are the same

Att8c. Bhutanese and Burmese only

62. Do you receive food stamps?

Att8c. Bhutanese and Burmese only

62. Does anyone in your household receive food stamps?

The wording is revised to capture information that better represents household ‘income’

Att8c. Bhutanese and Burmese only

62. Do you receive WIC services?

Att8c. Bhutanese and Burmese only

62. Does anyone in your household receive WIC services?

Att8g. Subsistence Anglers only

56. Have you heard about the health advice on eating fish caught from New York State waters?

___ Yes

Att8g. Subsistence Anglers only

56. Have you heard about the health advice on eating fish caught from New York State waters?

___ Yes, From who or where did you hear it? _________________________________

Revised to collect source of fish advisory information

Network Questionnaire

Att8d. Bhutanese and Burmese

Att8h. Subsistence Anglers

Network Questionnaire

Att8d. Bhutanese and Burmese

Att8h. Subsistence Anglers

3. If there are people you would not refer to this project, why would you not refer all of them? Read list of reasons.

Check all that apply.

___ [Reason 1]

___ [Reason 2]

___ [Reason 3]

___ Other  Specify: __________________________________

___ Don’t know ___ Refused

3. If there are people you would not refer to this project, why would you not refer all of them? Read list of reasons.

Check all that apply.

___ [They already participated]

___ [They work so are unable to come to the events]

___ [I don’t know where they live]

___ Other  Specify: __________________________________

___ Don’t know ___ Refused

Grammatical correction

Recent analysis of the Biomonitoring I program data revealed these reasons as frequent responses. The [Reason #] boxes are now filled in