Appointment Verification Letter

Appendix A.3 Appointment Verification Letter

PFAS Environmental Sampling at Select Exposure Assessment Locations

Appointment Verification Letter

Reading Level: 8.1

Dear [Insert Name],

CDC/ATSDR thanks you for being part of the environmental sampling for PFAS that is being conducted in your community.

You have (an) appointment(s) to conduct the sampling at your home on:

Date and Time (put in two dates if two appointments)

The appointment will take about an hour (or each appointment will take about 2 hours).

We ask that you do the following prior to the sampling:

• Please do not vacuum the carpets in your home for at least 5 days prior to the sampling

The following statement will only be included for those homes with additional sampling being done:

• Please do not empty your vacuum cleaner (bag or bagless) since we will be collecting the dust for analysis when we arrive at your home

Enclosed are appropriate consent forms and questionnaires for everyone in your household that provided blood samples during the Exposure Assessment. The forms should be filled out as follows:

One adult in the home that provided a blood sample during the Exposure Assessment will be asked to:

• Sign a consent form to complete the questionnaires and to allow ATSDR to complete the sampling (Adult Consent 1),

• Fill out a household questionnaire, and

• Fill out a personal exposure questionnaire.

This adult will wear up to three silicone wristbands for one week to evaluate personal exposure to PFAS both at home and away from the home. We will ask that you remove the wristbands when you bathe, shower or swim.

Other adults in the home that provided a blood sample during the Exposure Assessment will be asked to:

• Sign a consent form to complete the questionnaire (Adult Consent 2), and

• Fill out a personal exposure questionnaire.

For children in the home that provided a blood sample during the Exposure Assessment, the following should be completed:

• A parent/guardian in the home should complete the parental permission form for children younger than 18 years old,

• Children between 12 and 17 years old should fill out the assent form to agree to fill out the personal questionnaire, and

• Fill out the personal exposure questionnaire, with assistance from an adult as needed.

When we arrive at your home to complete the sampling, we will ensure that the consent forms and questionnaires have been completed properly. We would ask that people who won’t be present in the home during the sampling fill out the appropriate consent forms/questionnaires completely before we arrive so we can include them in the investigation. If you have questions regarding how to fill out the forms, please call XXX-XXX-XXXX.

Please let us know if you are unable to make your appointment by calling XXX-XXX-XXXX. We will attempt to reschedule your appointment if needed, but it will be difficult since we are sampling at many homes in your community.

You will receive a reminder call prior to your appointment.

Thank you again for participating!

SIGNTURE BLOCK

List out the forms that are included (consents and questionnaires)