P_Att20b_RequestChildSchlRecAbstrctn_20190813 clean

Pease Study

Request Child School Record Abstraction

Flesch-Kincaid Readability Score – 11.6

Form Approved

OMB No. 0923-xxxx

Exp. Date xx/xx/201x

Attachment 20b - Request for Child Sachool Record Abstraction

[ON AGENCY LETTERHEAD]

[DATE]

[NAME OF SCHOOL ADMINISTRATOR]

[ADDRESS]

[CITY, STATE ZIP CODE]

Subject: Educational records verification for Pease Study

Dear [NAME OF SCHOOL ADMINISTRATOR]:

The Agency for Toxic Substances and Disease Registry (ATSDR) is conducting a research study of the health effects from exposure to per- and polyfluoroalkyl substances (PFAS) found in Pease, NH, drinking water. We are working with the assistance of your local health department, the New Hampshire Department of Health and Human Services (NH DHHS), and [name of all other partners]. ATSDR is conducting this research study with oversight from the CDC/ATSDR Institutional Review Board (IRB) under CDC Protocol No. 7161.

Under Section 8006 of the 2018 Consolidated Appropriations Act, Congress authorized ATSDR to study the impact that exposure to PFAS in drinking water might have on the health of Pease citizens. This study will see if there is an increase of symptoms or illness related to these chemicals.

ATSDR will include about 350 children served by the Pease Tradeport Water System during the time of PFAS contamination. We have included a comparison group of about 175 children from Portsmouth, NH. ATSDR selected Portsmouth because it is very similar to Pease for social and economic factors; it has not experienced PFAS contamination in its water supply.

[PARENT OR GUARDIAN’S NAME] has given the study investigators authorization to conduct an educational records review for [CHILD PARTICIPANT’S NAME]. ATSDR is interested in comparing [CHILD PARTICIPANT’S NAME]’s existing school records to [his/her] behavioral test results from this research. We have included an abstraction form for your office to fill out and return to us in the enclosed return envelope.

If we need additional information, the ATSDR study team may wish to review the child’s educational records in your office. We would appreciate your assistance if this is necessary.

ATSDR is an agency of the U.S. Department of Health and Human Services. The requested information represents the minimum necessary to carry out the public health purposes of this study. The research is also covered by a Certificate of Confidentiality under Section 301(d) of the Public Health Service (PHS) Act, as amended by Section 2012 of the 21st Century Cures Act, P.L. 114-255 (42 U.S.C. 241(d))

For questions about this research study, please call the ATSDR study lead, Dr. Marian Pavuk, at [study telephone number]. Please leave a message with your name and a telephone number or address.

Thank you for your assistance.

Marian Pavuk, MD, PhD Frank Bove, DSc

Co-Principal Investigators

Pease Study

ATSDR estimates the average public reporting burden for this collection of information as 20 minutes per response, including the time for reviewing instructions, searching existing data/information sources, gathering and maintaining the data/information needed, and completing and reviewing the collection of information. An agency may not conduct or sponsor, and a person is not required to respond to a collection of information unless it displays a currently valid OMB Control Number. Send comments regarding this burden estimate or any other aspect of this collection of information, including suggestions for reducing this burden to CDC/ATSDR Information Collection Review Office, 1600 Clifton Road NE, MS D-74, Atlanta, Georgia 30333; ATTN: PRA (0923-xxxx).