Parental Permission Form - Children Younger than 18 Years of Age

Attachment 3C: Parental Permission Form for Children younger than 18 Years of Age

Flesch-Kincaid Reading level – 7.4

Parental Permission Form for Blood and Urine Testing

Children younger than 18 years of age

ATSDR Exposure Investigation (EI)

Anaconda, Montana

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 8 Environmental Protection Agency (EPA)

• Anaconda Deer Lodge County (ADLC) Health Department

• Montana Department of Public Health and Human Service (MDPHSS)

Why we are doing this Exposure Investigation (EI)?

• We are doing this EI to respond to community concerns about lead and arsenic in the environment and to help people find out if they are exposed

• We are testing lead in blood samples and arsenic in urine samples

What do we want you to do?

• Your child/ward is invited to have his/her blood tested for lead and urine tested for arsenic.

• There is NO COST to you for the testing of your child/ward.

• Collect your child’s/ward’s urine sample at home and bring it to the blood collection location.

• Complete a brief questionnaire with that will ask questions regarding how your child/ward may be exposed to lead and arsenic.

• Allow a licensed phlebotomist to take a sample of your child’s/ward’s blood.

What is included in my child’s/ward’s participation?

There are three parts to your participation.

1. Urine Collection and Testing for Arsenic

   1. The first morning urine sample from your child/ward that you collected at home and froze was brought to the blood testing location.

   2. We will send your child’s/ward’s urine to a lab to test it for arsenic.

   3. The urine will not be tested for drugs, alcohol or HIV.

2. Answer a Short Questionnaire

   1. We will ask you some questions about your home and how your child/ward might be exposed to lead and arsenic.

   2. This should take about 20 minutes.

3. Blood Collection and Testing for Lead

• We will collect less than 1 teaspoon (3 milliliters) from a vein in your child’s/ward’s arm.

• This will take 10 minutes or less.

• We will send your child’s/ward’s blood to a lab to test it for lead.

• The blood will not be tested for drugs, alcohol or HIV.

What will happen to any leftover blood after testing is finished?

• The blood and urine will not be used or tested for anything else.

• The lab will throw out any leftover blood and urine.

When will you get the test results?

• You will get your child’s/ward’s test results by mail about 12 weeks after testing.

What are the benefits of being in this EI?

• You will know the levels of lead in the blood and arsenic in the urine of your child/ward.

• If your child/ward is found to have high levels of lead or arsenic, ATSDR and ADLC will recommend you follow-up with your child’s/ward’s physician and will provide you with information that will help you reduce contact with lead and arsenic.

What are the risks of this EI?

• The needle stick might hurt a little.

• Some bruising may happen where the blood is taken.

• Your child/ward may feel a little lightheaded for a short time.

How will we protect your child’s/ward’s privacy?

• We will protect your child’s/ward’s privacy as much as the law allows.

  • Montana law requires that we report blood lead levels to the ADLC if the result is greater than 5 µg/dL.

  • Montana 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 share the results with other agencies only with your permission. We will require our government partners to treat your information as private.

• We will give your child/ward an identification (ID) number.

  • Your child’s/ward’s ID number, not their name, will go on the tube of blood and urine sample.

  • We will keep a record, under lock-and-key, of your child’s/ward’s name, address, and ID number. The information will be used by ATSDR to link the results to each person and send your blood and urine test results to you.

• We will not use your child’s/ward’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. Luly Rosales-Guevara at 770-488-0744

  • Dr. Matt Karwowski at 404-718-5867

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

Parental/Guardian Voluntary Permission

• I agree to have my child/ward tested.

• I agree to answer questions about my child/ward.

• I was given the chance to ask questions on behalf of my child/ward. I feel my questions have been answered.

• I know that having these tests done is my choice for my child.

• I know that even though we agreed to this testing, my child/ward may leave at any time without penalty.

1. Regardless of the results, may we share the test result with other federal, state, and local health and environmental agencies? YES / NO (please circle one)

2. If the results are 5 µg/dL or greater, can we provide your information to the Pediatric Environmental Health Specialty Unit (PEHSU), and may they contact you for follow-up? YES / NO (please circle one)

Signature

I give permission for my child/ward to be tested and agree to answer questions about my child/ward.

______________________________________ ______ ___________

Printed name of child Age Sex of child

___________________________________ __________________

Signature of parent/guardian Date

___________________________________

Printed name of parent/guardian

Address of Child _____________________________ Telephone __________________

______________________________

______________________________

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