Adult Consent 2

Appendix B3: Adult Consent Form 2

PFAS Environmental Sampling at Select Exposure Assessment Sites

Adult Consent Form for Questionnaire

Flesch-Kincaid Reading Level: 10.6

Thank you for participating in the environmental sampling EI.

This Adult Consent Form 2 should be completed by adults in the household that provided a blood sample during the Exposure Assessment that did not complete Consent Form 1. The person will also agree to complete:

• 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 (EI) that will measure per- and polyfluoroalkyl substances (PFAS) at your home. 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 investigation 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 a personal exposure questionnaire to look at potential PFAS exposure both inside and outside your home.

This form contains information about 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 Questionnaire Completion

1. CDC/ATSDR will ask you to agree to complete a personal exposure questionnaire that will evaluate potential personal PFAS 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 results of the environmental sampling done at your home. If CDC/ATSDR sampled tap water and dust samples as part of the EA, we would also like to use those PFAS results. At the end of the investigation, the results of the sampling done in your household will be sent to your home in a letter (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.

It will take about 15 minutes to complete the personal exposure questionnaire.

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 by completing the personal questionnaire. It will take about 15 minutes to complete.

Additional Information:

• Results: We will send your household 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. 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 complete the 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 my household will receive the results of the environmental sampling in a letter (electronically or by mail).

 Yes  No

I agree that my household’s 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 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:______________________