Human Exposure to Cynobacterial (Blue-green Algal) Toxins in Drinking Water: Risk of Exposure to Microcystins from Public Water Systems

Attachment 3

Screening Questionnaire

Form Approved

OMB No.: 0920-0527

Expiration Date:

Human Exposure to Cyanobacterial Toxins in Water

Eligibility Screening Questionnaire

Hello, I’m ___________________. I’m working with the Centers for Disease Control and Prevention and the California Department of Public Health. I’d like to know if you are willing to help us with a blue-green algae research study today. Have you seen our study ad?

You may have heard about blue-green algae. They are very tiny organisms that grow in water. One type of blue-green algae is called Microcystis aeruginosa. This type of blue-green algae can make chemicals, called microcystins, that can make people sick. For example, we know these chemicals can cause liver problems in people when they drink water with a lot of this chemical in it.

We are doing a research study to see if small amounts of blue green algae can be found in the nose and blood of people doing recreational activities on lakes with algae blooms. We also want to know if we can find very small amounts of microcystins in blood samples of people who have been working, swimming, or playing in waters. We would like people to answer some questions and give us a small (about 2 teaspoons each) blood sample today. We would also like to call you in about 10 days and ask you some questions.

Public reporting burden for this collection of information is estimated to average 5 minutes per response, including the time for reviewing instructions, searching existing data sources, gathering and maintaining the data 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 Reports Clearance Officer; Paperwork Reduction Project (0920-0527); M.S. D-24; 1600 Clifton Road NE, Atlanta, Ga. 30333

Will you help us with our study?

IF NO:

Okay, well, thank you for your time.

IF YES:

Thank you.

First, I will ask you some questions to see if you qualify to be in our study.

Then I’ll ask you to read and sign a consent form and answer a few more questions.

If you are using a jet ski or a boat (for collecting water samples or other work-related activities, sailing, or for water skiing), we will also ask you to take a personal air monitor with you.

At the end of the day today, you will come back here and answer the same questions and give us a blood sample.

This should only take about 30 minutes of your time.

In about 10 days, someone from the study will call you and ask some questions about symptoms you may have.

We will give you $40 for completing all parts of the study.

OK?

IF PERSON IS INTERESTED IN BEING IN THE STUDY

Okay, I am going to read a list of activities and you can tell me which of these you plan to do today.

Yes No Don’t Know

Water Skiing ___ ___ ___

Sailing a small boat ___ ___ ___

Jet Skiing ___ ___ ___

Swimming ___ ___ ___

Fishing from a boat ___ ___ ___

Collecting water samples ___ ___ ___

Other work activity

Specify _______________________________________________

IF THEY CHOOSE “YES” TO ONE OR MORE OF THE ABOVE ACTIVITIES:

Thanks. You are eligible to be in our study.

IF THEY DO NOT CHOOSE “YES” TO ONE OR MORE OF THE ABOVE ACTIVITIES:

Thanks. But we can only include people who will be doing at least one of these activities today.

OMB Application_ Microcystins in Drinking Water.wpd Page 3