Adult Consent 1

Appendix B2: Adult Consent Form 1

PFAS Environmental Sampling at Select Exposure Assessment Sites

Adult Consent Form

Flesch-Kincaid Reading Level: 9.9

Thank you for participating in the environmental sampling EI.

This Adult Consent Form 1 should be completed by one adult in the household that provided a blood sample during the Exposure Assessment. The person will also agree to complete:

• The Household Questionnaire

• The Adult Personal Exposure Questionnaire

Only one adult in the household needs to complete this form allowing ATSDR to collect environmental samples in your home. Other adults in the household will complete Adult Consent Form 2 and the Adult Personal Exposure Questionnaire.

ATSDR will pick up this form from you when we come to your home for the environmental sampling.

You are invited to take part in an environmental sampling Exposure Investigation that will measure per- and polyfluoroalkyl substances (PFAS) at your home in environmental samples. We are trying to find out the levels of PFAS in the homes of people who participated in the PFAS Exposure Assessment (EA) in (Insert name of city/town/place here).

We want to give you some information about it so you can decide whether you want to participate.

The main goal for this environmental sampling is to look at non-drinking water sources of PFAS by sampling things like inside air, dust, and soil at your home. We will ask you to fill out this consent form and two questionnaires to look at potential PFAS exposure both inside and outside your home.

This form contains information about the sampling and what will happen if you decide to participate. If you agree to take part in this PFAS sampling, please sign at the end of the form.

PFAS Environmental Sampling and Questionnaire Completion

CDC/ATSDR will ask you to agree to the following to be included in the Exposure Investigation:

1. We will ask you to allow us to collect environmental samples at your home for PFAS analysis, as follows:

   1. An indoor dust sample will be collected at all homes using a pump and a small dust collection filter.

   2. At some homes (locations already identified), we will also take samples of the following:

• Indoor air: An air sampling unit will be put in a central location within your home. The unit will be left running nonstop for one week. We will pick up the sampling unit one week from the day it was put in

• Bulk Dust Sample: A sample of dust will be taken from the vacuum cleaner in your home

• Surface wipe samples: Two wipe samples will be taken on hard surfaces in your home

• Soil: Soil samples will be taken in your yard

• Wristband: The person who signs this form will be asked to wear up to 3 silicone wristbands continuously (except when showering, bathing, or swimming) for one week. We will pick up the wristbands one week from the day they are provided.

1. We will label your samples with a code only. Only the project coordinator will be able to identify whose house the samples are from. The samples will be sent to a laboratory for PFAS analysis.

2. Methods to measure PFAS in environmental samples are still being improved. It is possible that new methods will be found in the future that will increase our ability to measure PFAS in these types of samples. We would like to keep your collected samples and store them at EPA so that scientists can test for more PFAS in the future, if new tests are found. To do this, we need your permission.

1. We will ask you to fill out two questionnaires:

   1. A household questionnaire that asks questions about your home

   2. A personal exposure questionnaire that asks questions about your personal exposure, such as questions about your diet.

2. We will ask you to allow CDC/ATSDR to use the results of the PFAS blood sampling and the questionnaire from the EA to evaluate the environmental sample results. If CDC/ATSDR sampled tap water and dust samples in your home as part of the EA, we would also like to use those PFAS results. At the end of the investigation, we will send you a letter with your results (email or through the mail). If you would like to talk with an CDC/ATSDR staff person about your results, you can, free of charge.

Time required to participate in the environmental sampling and questionnaire

For those homes where an indoor dust sample is taken and the questionnaires are administered, a one-hour appointment will be required. Your household will receive a $20 gift card as a token of our appreciation for your participation.

For those homes where the more robust sampling is conducted and the questionnaires are administered, two, 2-hour appointments, one week apart will be required. Your household will receive a $20 gift card as a token of our appreciation for your participation for each appointment for a total of $40.

There will be no cost to you for the sample collection or the laboratory analysis. No blood or urine sampling will be completed as part of this EI.

The Benefits of Taking Part in Our Exposure Investigation

Your participation in this investigation will help us better understand exposure to PFAS that is not in drinking water. You will find out the levels of PFAS in your home.

We will be providing a $20 gift card per household as a token of appreciation for completing the indoor dust sampling. An additional $20 gift card (for a total of $40) will be provided to those households that complete additional environmental sampling.

The Risks of Taking Part in Our Exposure Sampling

You might be inconvenienced. CDC/ATSDR will need to have access to your home for up to two appointments, one week apart, to collect the samples and to fill out the questionnaire. Overall, it will take between 1 and 4 hours over one or two appointments to complete the sampling, depending on the types of samples we collect in your home. In addition, an air sampling unit may be placed inside your home and will run nonstop for a week. The unit may cause some minor noise inside your home.

Additional Information:

• Results: We will send you a letter (by mail or electronically) with the PFAS results for the samples taken at your home.

• Privacy: All personally identifiable information (PII) (such as name, address, date of birth) gathered for the PFAS sampling is private and will not be made public. This information is protected according to federal and state laws regarding privacy protection. Only trained and authorized project staff will be allowed to look at information that can identify you. We will keep all of the information in a secure, locked database or file at all times. Except for the environmental sampling EI team, you are the only one who will receive your individual results. In accordance with CDC/ATSDR’s policy regarding data access, sampling results that do not include PII may be used by public health researchers for approved research purposes.

• Voluntary Participation: Participation in this investigation is completely voluntary. Even if you decide to take part, you are free to quit the investigation at any time. If at any time in the future, you would like to have your samples destroyed or removed from the EI, please call Karen Scruton at 770-488-1325.

Consent Form

By marking the check boxes below and signing this form, you are confirming that you understand the goals of the PFAS sampling, and that you agree, of your own free will, to participate. You are also confirming you will allow the project staff to collect, store, and share the information collected as described above. You will receive a copy of this form for your records.

I agree to allow samples to be collected from my home and analyzed for PFAS.

 Yes  No

I agree to complete the household and personal exposure questionnaire for the environmental sampling Exposure Investigation.

 Yes  No

I agree to allow the blood and environmental samples (tap water and dust, if applicable), collected during the EA, to be used to evaluate the environmental sampling EI sampling results.

 Yes  No

I understand that I will receive my sampling results in a letter (electronically or by mail).

 Yes  No

I agree that the PFAS environmental sampling results may be shared with other federal, state, and local environmental and health agencies. Identifying information will be protected to the extent possible by law should you choose to share the results with other federal, state or local agencies.

 Yes  No

I agree that my samples may be saved for future PFAS-related analysis and that any leftover samples will be sent to EPA for storage and potential analysis in the future. If the samples are analyzed in the future, you will receive the results.

 Yes  No

I agree to let CDC/ATSDR keep my contact information and contact me in the future for possible follow-up studies (may be research or non-research studies).

 Yes  No

Participant’s Name:____________________________________________________________________

(Printed)

Participant’s Signature:_________________________________________________________________

Date Signed:________________________________________________________________________

Address for your results:

Street Address: _______________________________________________________

City: ________________________________ State: ________ Zip: ________

Phone number (area code): __________________________________

Project Representative’s Name:____________________________________________________________

(Printed)

Project Representative’s Signature:_________________________________________________________