Assent Form for Blood Lead and Questionnaire Youth 6-17 Years of Age

Attachment 3B: Assent Form for Children and Youth 6 to 17 Years of Age

Flesch-Kincaid Reading level – 4.5

Assent Form for Blood Lead and Questionnaire

Youth 6 years to 17 years of age

ATSDR Exposure Investigation (EI)

Iola, Kansas

Who are we?

• We are from a federal public health agency, the Agency for Toxic Substances and Disease Registry (ATSDR)

Who are we working with?

• Region 7 Environmental Protection Agency (EPA)

• Kansas Department of Health and the Environmental (KDHE)

• South Eastern Kansas Multi County Health Department (SEKMCHD) and

• Region 7 Pediatric Environmental Health Specialty Unit (PEHSU)

Why we are doing this Exposure Investigation (EI)?

• We are doing this EI to find out if children and youth living in the city of Iola, Kansas have high levels of lead in their blood.

What are we asking you to do?

• You are invited to have your blood tested for lead.

• There is NO COST to you or your parents for the testing.

• The blood collection will take place at _______________________.

What is included in my participation?

There are two parts to your participation.

1. Blood Collection and Testing for Lead

• We will take less than 1 teaspoon (3 milliliters) of blood from your arm.

• This will take 10 minutes or less.

• We will send your blood to a lab to test it for lead.

2. Answer Some Questions

• During the appointment we will ask you some questions.

• This will take about 20 minutes.

• Your parents can help you with the questions, if you want.

What will happen to any leftover blood?

• It will not be tested or used for anything else.

• The lab will throw out any leftover blood.

When will you get the test results?

• Your parents will get your test results by mail about 12 weeks after testing.

What are the benefits from being in this EI?

• Your parents and you will know if you have a high level of lead in your blood.

• If you have a blood lead level that is 5 µg/dL or higher, ATSDR and Region 7 PEHSU can provide you and your parents with information that can help you reduce your contact with lead.

What are the risks of this EI?

• The needle stick might hurt a little.

• Your arm may get a black and blue mark where the blood is taken.

• You may feel a little dizzy for a short time.

How will we protect your privacy?

• We will protect your privacy as much as the law allows. Kansas Department of Health and the Environment (KDHE).

  • Kansas law requires that information given to the state may be made public if someone asks them for the information but your name and address will not be released.

• We will give you an identification (ID) number.

  • We will use your ID number on the tube of blood.

  • We will keep a record, under lock-and-key, of your name, address and ID number so we can send the test results to your parents.

• We will not use your name in any report we write. Only group information that does not include your name will be reported.

When can you ask questions about the testing?

• If you have any questions about this testing, you can ask us now.

• If you have questions later, you can call:

  • Dr. Luly Rosales-Guevara at (770) 488-0744 or

  • The Iola Exposure Investigation toll free number (888) 892-1320

Child Assent

• Your parent/guardian said it is all right for you to have the blood test.

• Your parent/guardian said it is all right for you to answer some questions.

• You don’t have to have this test to answer questions if you don’t want to.

Voluntary Assent

• I agree to be tested.

• I agree to answer questions.

• I was given the chance to ask questions and feel my questions were answered.

• I know that having this test done is my choice.

• I know that even though I have agreed to this testing, I may leave at any time without penalty.

Signature

I agree to be tested and to answer questions.

_________________________________________ ___________ ______________

Printed name of child Age of child Sex of child

______________________________________________ __________________

Signature or written name of child in child’s handwriting Date

__________________________

Printed name of parent/guardian

Address of child ______________________________ Telephone __________________

______________________________

______________________________

Lab ID Number____________________

Certification of Assent Form Administrator:

I read the assent form to the person named above. He/she had the opportunity to ask questions about the Exposure Investigation and had the questions answered.

_______________________________________

Signature of person administering the assent