Attachment 3A: Parental Permission Form for Children 6 to less than 18 Years of Age
Flesch-Kincaid Reading level – 4.9
Follow Up Biologic Testing for Exposure to Arsenic
ASARCO Hayden Smelter Site, Hayden & Winkelman, Arizona Exposure Investigation
Parental Permission Form for Urine Arsenic Testing and Questionnaire
Children and Youth 6 years to less than 18 years of age
Who are we?
We are from a federal public health agency, the Agency for Toxic Substances and Disease Registry (ATSDR), and the Arizona Department of Health Services (ADHS).
Why we are doing this Exposure Investigation?
We are doing this Exposure Investigation to find out if children living in Hayden or Winkelman, AZ have high levels of arsenic in urine.
What do we want you to do?
Your child is invited to have his/her urine tested for arsenic.
There is NO COST to you for the testing of your child.
Place for Blood and Urine Collection
The urine collection will take place in your home or at XXX.
What
is included in my child’s participation?
There
are two parts to your child’s participation.
Urine Collection and Testing for Arsenic:
You can collect the urine at your home or at the designated urine collection facility.
Help your child collect his/her urine in a plastic cup we give you. Put the lid on.
Write your child’s name on the label on the side of the cup.
Put the cup in a zip lock bag in the refrigerator until you bring it to XXX.
It should take 5 minutes or less to help collect your child’s urine.
We will send your child’s urine to a lab to test it for arsenic.
Answer Some Questions:
During the appointment we will ask your child some questions for 20 min.
You may help your child answer the questions.
What will happen to any leftover urine after testing is finished?
The lab will throw out any leftover urine. It will not be used for anything else.
When will you get the test results?
You will get your child’s test results by mail about 12 weeks after testing.
What are the benefits from being in this Exposure Investigation?
You will know if your child has a high level of arsenic in urine.
If your child has a high urine arsenic level, ATSDR and ADHS will provide you with information that can help you reduce your child’s contact with arsenic.
What are the Risks of this EI?
There is no risk from collecting urine.
How will we protect your privacy?
We will protect your and your child’s privacy as much as the law allows.
Arizona law requires that information given to the state may be made public if someone asks them for the information.
We will give your child an identification (ID) number.
Your child’s ID number, not his/her name, will go on the urine cup.
We will keep a record, under lock-and-key, of your child’s name, address and ID number. We will use this information to link your child’s results with his/her name so we can send you your child’s test results.
We will not use your or your child’s name in any report we write. Only group information that does not include individual names 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. Bruce Tierney at 770-488-0771
The ATSDR toll free number 1-888-320-5291
Child Assent
Your child said it is alright to have this urine test.
Your child doesn’t have to have this test if you don’t want him/her to.
Parental/Guardian Voluntary Permission
I agree to have my child tested.
I and my child were given the chance to ask questions. We feel our questions have been answered.
I know that having these tests done is our choice.
I know that even though we agreed to this testing, I and my child may leave at any time without penalty.
Signature
I give permission for my child to be tested.
______________________________________ ___________ ___________
Printed name of child Age of child Sex of child
___________________________________ __________________
Signature of parent/guardian Date
___________________________________
Printed name of parent/guardian
______________________________________________ __________
Signature or written name of child in child’s handwriting Date
Address
of Child _____________________________ Telephone
__________________
______________________________
______________________________
May we share the test results with other federal, state, and local health and environmental agencies? YES / NO (please circle one)
Lab ID Number____________________
Certification of Permission Form Administrator:
I read the permission 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 permission
| File Type | application/vnd.openxmlformats-officedocument.wordprocessingml.document |
| File Modified | 0000-00-00 |
| File Created | 2021-01-22 |