Assent/Consent

Attachment 3

Assent/Consent/Parental Permission Forms

Colorado Smelter EI

Attachment 3A

Parental Consent Form for Blood Sampling for Lead

Children 9 to 72 months of age

ATSDR Exposure Investigation (EI)

Colorado Smelter, Pueblo, CO.

Who are we and why we are doing this EI?	We are from the Agency for Toxic Substances and Disease Registry (ATSDR), Centers for Diseases Control and Prevention (CDC) We are doing this Exposure Investigation to find out if children 9 to 72 months from Pueblo, CO. have high levels of lead in blood We are inviting your child/ward to have his/her blood tested for lead

Location for the testing

The blood testing will take place at: St. Mary’s Church in Eilers

What is involved in this EI?

Blood Test: We will collect 3 milliliters (ml) of blood (less than a teaspoon) from a vein in your child/ward’s arm. This will take 5 minutes or less Short questionnaire: We will give a short questionnaire, this will take 15 to 20 minutes

What will happen with the left over blood?

The leftover blood will be discarded and not used for anything else

When will we get the results?

You will receive your child/ward test results by mail 14 to 18 weeks after testing

What are the Benefits from being in this EI?

You will know if your child/ward has an elevated level of lead in blood There is NO COST to you for the testing of your child/ward

What are the Risks from participating in this EI?	Some bruising may occur in the location of your child/ward arm where the blood is collected

What about Privacy?

We will protect your child/ward’s privacy as much as the law allows We will give your child/ward an identification (ID) number This ID number, not your child/ward’s name, will go on the blood sample We will not use your child/ward’s name in any report we write We will keep a record under locked key, of your child/ward’s name, address and ID number so that we can send you the blood test result. The information will be used by ATSDR scientist to link the results with each individual and send the blood and urine test results to you.

When can we Ask Questions?

If you have any questions about this testing, you can ask us now If you have questions later, you can call: Dr. Lourdes (Luly) Rosales-Guevara at 770-488-0744, or Cell phone: 404-272-8902 Or at the ATSDR toll free number 1-888-320-5291

Parental/Guardian Voluntary Consent

I agree to have my child/ward tested for lead in blood I was given the chance to ask questions on my child/ward behalf and feel my questions were answered I know that having this test done is our choice I know that even though we have agreed to this testing, my child/ward may leave it at any time without penalty

Signature

I give permission to test my child/ward

Printed name of Child

______________________________ __________________

Signature of Parent/Guardian Date

______________________________

Printed Name of Parent/Guardian

Age of Child_________ Gender of Child__________

Address of Child_____________________________

______________________________

______________________________

Telephone__________________

May we share this test results with other Federal or State Health and Environmental Agencies? YES_____________, NO____________

Lab ID Number____________________

Certification of Consent Form Administrator:

I have read the consent form to the person name above. He/she has had the opportunity to ask questions about the EI and had the questions answered.

_______________________________________

Signature of person administering consent

Attachment 3B

Parental Consent Form for Blood Sampling for Lead and

Urine Sampling for Arsenic

In Children 6 to 17 years of age

ATSDR Exposure Investigation (EI)

Colorado Smelter, Pueblo, CO

Who are we and why we are doing this EI?

We are from the Agency for Toxic Substances and Disease Registry (ATSDR), Centers for Diseases Control and Prevention (CDC) We are doing this EI to determine if children 6 to 17 years of age from Pueblo, CO. have high levels of lead in blood and arsenic in urine We are inviting your child/ward to have his/her blood tested for lead and urine for arsenic

Location for the testing

The blood testing will take place at St. Mary’s Church in Eilers

What is involved in this EI?

Blood Lead Testing: We will collect 3 milliliters (ml) of blood (less than a teaspoon) from a vein in your child/ward’s arm This will take 5 minutes or less Urine Arsenic Testing: At home: On the day of the testing, help your younger child/ward collect urine in a plastic cup we give you Put your child/ward’s name on the label in the side of the cup Help your child/ward put the urine cup in a zip lock bag in your refrigerator until you bring it up to St. Mary’s Church in Eilers It should take 5 minutes or less to help collect your child/ward’s urine sample A short questionnaire will be administered: This will take 15 to 20 minutes

What will happen with the leftover blood and urine?

The leftover blood and urine will be discarded and not used for anything else

When will we get the results?

You will get your child/ward’s results by mail 14 to 18 weeks after testing

What are the Benefits from being in this EI?

You will know if your child/ward has an elevated level of lead in blood and arsenic in urine There is NO COST to you for the testing of your child/ward

What are the Risks of this EI?

Some bruising may occur in the location of your child/ward arm where the blood is collected There is no risk from collecting urine

Child Assent

Your parent/guardian said it is all right for you to have this blood and urine tests You don’t have to have these tests if you don’t want to

What about Privacy?

We will protect your child/ward’s privacy as much as the law allows We will give your child/ward an identification (ID) number This ID number, not your child/ward’s name, will go on the blood and urine sample We will not use your child/ward’s name in any report we write We will keep a record, under locked key, of your child/ward’s name, address and ID number so that we can send you the tests results. The information will be used by ATSDR scientist to link the results with each individual and send the blood and urine test results to you.

When can you Ask Questions?

If you have any questions about this testing, you can ask us now If you have questions later, you can call: Dr. Lourdes Rosales-Guevara at 770-488-0744 or Cell: 404-272-8902 Or at ATSDR toll free number 1-888-320-5291

Parental/ Guardian Voluntary Consent

I agree to have my child/ward tested I and my child/ward were given the chance to ask questions and feel our questions have been answered I know that having these tests done is our choice I know that even though we have agreed to these testing, my child/ward may leave it at any time without penalty

Signature

I give permission for my child/ward to be tested

Printed name of Child

__________________________________ _______________

Signature of Parent/Guardian Date

____________________________________

Printed Name of Parent/Guardian

__________________________________ ___________

Signature/written name of child in child’s handwriting Date

Age of Child_______________ Gender of Child_______________

Address of Child________________________________________

________________________________________

________________________________________

Telephone__________________________

May we share this test results with other federal or state health and

environmental agencies? YES___________ NO_______________

Lab ID Number________________________

Certification of Consent Form Administrator

I have read the consent form to the person named above. He/she has had the opportunity to ask questions about the EI and had the questions answered.

_____________________________________

Signature of person administering consent

Attachment 3C

Assent Form for Blood Sampling for Lead and

Urine Sampling for Arsenic

In Children 12 to 17 years of age

ATSDR Exposure Investigation (EI)

Colorado Smelter, Pueblo, CO

Who are we and why we are doing this EI?

We are from the Agency for Toxic Substances and Disease Registry (ATSDR) We are doing this EI to see if children from 12 to 17 years of age from Pueblo, CO. have high levels of lead in blood and arsenic in urine We are inviting you to have your blood tested for lead and urine for arsenic

Location for the testing

This testing will take place at St. Mary’s Church in Eilers

What is involved in this EI?

Blood Lead Testing: A 3 ml sample of blood (less than a teaspoon) will be collected from a vein in your arm This will take 5 minutes Urine Arsenic Testing: On the day of the test, ask your parents to help you collect urine at home in a plastic cup we gave them You will put your name on the label in the side of the cup You will put the urine cup in a zip lock bag in your freezer until you bring it up to an ATSDR person at St. Mary’s Church in Eilers It should take 5 minutes or less for you to collect your urine sample A short questionnaire will be administered: This will take 15 to 20 minutes

What will happen with the leftover blood and urine?

Any leftover blood and urine will be tossed out and not used for anything else

When will we get the results?

You will get your results by mail 12 - 14 weeks after testing

What are the Benefits from being in this EI?

By being part of this EI, you will find out if you have an elevated level of lead in blood and arsenic in urine There is NO COST to you for the testing

What are the Risks of this EI?

There may be some black and blue in the bend of your elbow where the blood is collected There is no risk from collecting urine

Child Assent

Your parent/guardian said it is all right for you to have this blood and urine tests You don’t have to have these tests if you don’t want to

What about Privacy?

We will protect your privacy as much as the law allows We will give you an identification (ID) number This number, not your name, will go on the blood and urine sample We will not use your name in any report we write We will keep a record, under locked key, of your name, address and ID number so that we can send you the tests results

When can you Ask Questions?

If you have any questions about this testing, you can ask us now If you have questions later, you can call: Dr. Lourdes Rosales-Guevara at 770-488-0744 or Cell: 404-272-8902 Or at ATSDR toll free number 1-888-320-5291

Voluntary Consent

I agree to be tested I have been given the chance to ask questions and feel our questions have been answered I know that having this tests done is my choice I know that even though I agreed to these testing, I may leave it at any time without penalty

Signature

I agreed to be tested

Printed name of Child

__________________________________ _______________

Signature of Child Date

__________________________________

Printed Name of Parent/Guardian

Age of Child_______________ Gender of Child_______________

Address of Child________________________________________

________________________________________

________________________________________

Telephone__________________________

May we share this test results with other federal or state health and

environmental agencies? YES___________ NO_______________

Lab ID Number________________________

Certification of Assent Form Administrator

I have read the assent form to the person named above. He/she has had the opportunity to ask questions about the EI and had the questions answered.

_____________________________________

Signature of person administering the assent

Attachment 3D

Assent Form for Blood Sampling for Lead and

Urine Sampling for Arsenic

In Children 6 to 11 years old

ATSDR Exposure Investigation (EI)

Colorado Smelter, Pueblo, CO

Who are we and why we are doing this EI?

We are from the Agency for Toxic Substances and Disease Registry (ATSDR) We are doing an Exposure Investigation to see if children from 6 to 11 years of age from Pueblo, CO. have high levels of lead in blood and arsenic in urine We are inviting you to have your blood tested for lead and urine for arsenic

Location for the testing

This testing will take place at St. Mary’s Church in Eilers

What is involved in this EI?

Blood Lead Testing: A bit of blood (less than a teaspoon) will be collected from your arm This will take 5 minutes Urine Arsenic Testing: Your parents will help you collect your urine in a cup we gave them It takes 5 minutes to collect your urine We will ask you some questions for 10 - 15 minutes and your parents will be able to help you

What will happen with the leftover blood and urine?

If there is blood or urine left we will toss it out and not used for anything else

When will we get the results?

You will get your results by mail in 12 - 14 weeks after testing

What are the Benefits from being in this EI?

By being part of this EI, we will be able to tell your parents if you have a high level of lead in blood and arsenic in urine There is NO COST to you for the testing

What are the Risks of this EI?

There may be some black and blue in your arm where the blood is collected There is no risk from collecting urine

Child Assent

Your parent/guardian said it is all right for you to have this blood and urine tests You don’t have to have these tests if you don’t want to

What about Privacy?

We will protect your privacy as much as the law allows We will give you an identification (ID) number This number, not your name, will go on the blood and urine sample We will not use your name in any report we write We will keep a record, under locked key, of your name, address and ID number so that we can send you the tests results

When can you Ask Questions?

If you have any questions about this testing, you can ask us now If you have questions later, you can call: Dr. Lourdes Rosales-Guevara at 770-488-0744 or Cell: 404-272-8902 Or at ATSDR toll free number 1-888-320-5291

Voluntary Consent

I agree to be tested I have been given the chance to ask questions and feel our questions have been answered I know that having this tests done is my choice I know that even though I agreed to these testing, I may leave it at any time without penalty

Signature

I agreed to be tested

Printed name of Child

__________________________________ _______________

Signature of Child Date

__________________________________

Printed Name of Parent/Guardian

Age of Child_______________ Gender of Child_______________

Address of Child________________________________________

________________________________________

________________________________________

Telephone__________________________

May we share this test results with other federal or state health and

Environmental agencies? YES___________ NO_______________

Lab ID Number________________________

Certification of Assent Form Administrator

I have read the assent form to the person named above. He/she has had the opportunity to ask questions about the EI and had the questions answered.

_____________________________________

Signature of person administering the assent

Attachment 3E

Consent Form for Blood Sampling for Lead and

Urine Sampling for Arsenic in

Pregnant Women

ATSDR Exposure Investigation (EI)

Colorado Smelter, Pueblo, CO

Who are we and why we are doing this EI?

We are from the Agency for Toxic Substances and Disease Registry (ATSDR), Centers for Diseases Control and Prevention (CDC) We are doing this EI to find out if pregnant women of any age from Pueblo, CO. have high levels of lead in blood and arsenic in urine We are inviting you to have your blood tested for lead and urine tested for arsenic

Location for the testing

The blood testing will take place at St. Mary’s Church in Eilers

What is involved in this EI?

Blood Lead Testing: We will collect 3 milliliters (ml) of blood (less than a teaspoon) from a vein in your arm This will take 5 minutes or less Urine Arsenic Testing: You will collect your urine sample in a plastic cup we give you You will write your name on the label on the side of the cup You will put capped plastic cup in a zip lock bag in the refrigerator until you bring it to t St. Mary’s Church in Eilers It should take 5 minutes of less for you to collect your urine sample Short Questionnaire: We will give you a short questionnaire This should take 15 to 20 minutes

What will happen with the left over blood and urine?

The leftover blood and urine will be discarded and not used for anything else

When will we get the results?

You will get your test results by mail 14 to 18 weeks after testing

What are the Benefits from being in this EI?

You will know if you have high level of lead in blood and arsenic in urine There is NO COST to you for the testing

What are the Risks of this EI?	Some bruising may occur at the location the blood is collected from. There is no risk from collecting urine

What about privacy?

We will protect your privacy as much as the law allows We will give you an identification (ID) number This ID number, not your name, will go on the blood and urine sample We will not use your name in any report we write We will keep a record, under locked key, of your name, address and ID number. The information will be used by ATSDR scientist to link the results with each individual and send the blood and urine test results to you.

When can we ask questions?

If you have any questions about this testing, you can ask us now If you have questions later, you can call: Dr. Lourdes Rosales-Guevara at 770-488-0744 or Cell: 404-272-8902 Or at the ATSDR toll free number 1-888-320-5291

Voluntary Consent

I agree to be tested I was given the chance to ask questions and feel my questions were answered I know that having these tests done is my choice I know that even though I have agreed to this testing, I may leave at any time without penalty

Signature

I give my permission to be tested

______________________________ __________________

Signature of Person Given Consent Date

Age _________

Address _____________________________

______________________________

______________________________

Telephone__________________

May we share this test results with other federal or state health and

environmental agencies? YES_____________, NO____________

Lab ID Number____________________

Certification of Consent Form Administrator:

I read the consent form to the person name above. She had the opportunity to ask questions about the EI and had the questions answered.

_______________________________________

Attachment 3F

Consent Form for Blood Sampling for Lead and

Urine Sampling for Arsenic in

Women of childbearing age

ATSDR Exposure Investigation (EI)

Colorado Smelter, Pueblo, CO

Who are we and why we are doing this EI?

We are from the Agency for Toxic Substances and Disease Registry (ATSDR), Centers for Diseases Control and Prevention (CDC) We are doing this EI to find out if women of childbearing age from Pueblo, CO. have high levels of lead in blood and arsenic in urine We are inviting you to have your blood tested for lead and urine tested for arsenic

Location for the testing

The blood testing will take place at St. Mary’s Church in Eilers

What is involved in this EI?

Blood Lead Testing: We will collect 3 Milliliters (ml) of blood (less than a teaspoon) from a vein in your arm This will take 5 minutes or less Urine Arsenic Testing: Collect your urine sample at home in a plastic cup we give you Put your name on the label on the side of the cup Put the capped plastic cup in a zip lock bag in the refrigerator until you bring it to St. Mary’s Church in Eilers It should take 5 minutes or less for you to collect your urine sample Short questionnaire: We will give a short questionnaire, This should take 15 to 20 minutes

What will happen with the left over blood and urine?

Any leftover blood and urine will be discarded and not used for anything else

When will we get the results?

You will get your test results by mail 14 - 18 weeks after testing

What are the Benefits from being in this EI?

You will know if you have high level of lead in blood and arsenic in urine There is NO COST to you for the testing

What are the Risks of this EI?	There may be some bruising in the location where the blood is collected There is no risk from collecting urine

What about privacy?

We will protect your privacy as much as the law allows We will give you an identification (ID) number This ID number, not your name, will go on the blood and urine sample We will not use your name in any report we write We will keep a record, under locked key, of your name, address and ID number so that we can send you the blood and urine test result. The information will be used by ATSDR scientist to link the results with each individual and send the blood and urine test results to you.

When can we ask questions?

If you have any questions about this testing, you can ask us now If you have questions later, you can call: Dr. Lourdes Rosales-Guevara at 770-488-0744 or Cell: 404-272-8902 Or at the ATSDR toll free number 1-888-320-5291

Voluntary Consent

I agree to be tested I was given the chance to ask questions and feel my questions have been answered I know that having these tests done is my choice I know that even though I have agreed to this testing, I may leave it at any time without penalty

Signature

I give my permission to be tested

______________________________ __________________

Signature of Person Given Consent Date

Age _________

Address _____________________________

______________________________

______________________________

Telephone__________________

May we share this test results with other federal or state health and

environmental agencies? YES_____________, NO____________

Lab ID Number____________________

Certification of Consent Form Administrator:

I have read the consent form to the person name above. She has had the opportunity to ask questions about the EI and had the questions answered.

_______________________________________

Attachment 3G

Parental Consent Form for Blood Sampling for Lead and

Urine Sampling for Arsenic in

Minor Women of Childbearing Age

ATSDR Exposure Investigation (EI)

Colorado Smelter, Pueblo, CO

Who are we and why we are doing this EI?

We are from the Agency for Toxic Substances and Disease Registry (ATSDR), Centers for Diseases Control and Prevention (CDC) We are doing this EI to find out if women of childbearing age from Pueblo, CO. have high levels of lead in blood and arsenic in urine We are inviting you to have your blood tested for lead and urine tested for arsenic

Location for the testing

The blood testing will take place at St. Mary’s Church in Eilers

What is involved in this EI?

Blood Lead Testing: We will collect 3 milliliters (ml) of blood (less than a teaspoon) from a vein in your arm This will take 5 minutes or less Urine Arsenic Testing: You will collect your urine sample at home in a plastic cup we give you You will put your name on the label on the side of the cup You will put the capped plastic cup in a zip lock bag in the refrigerator until you bring it to St. Mary’s Church in Eilers It should take 5 minutes of less for you to collect your urine sample Short Questionnaire: We will give you a short questionnaire This should take 15 to 20 minutes

What will happen with the left over blood?

Any leftover blood and urine will be discarded and not used for anything else

When will we get the results?

You will get your test results by mail 12 - 14 weeks after testing

What are the Benefits from being in this EI?

You will know if you have high level of lead in blood and arsenic in urine There is NO COST to you for the testing

What are the Risks of this EI?	There may be some bruising in the location where the blood is collected There is no risk from collecting urine

What about privacy?

We will protect your privacy as much as the law allows We will give you an identification (ID) number This ID number, not your name, will go on the blood and urine sample We will not use your name in any report we write We will keep a record, under locked key, of your name, address and ID number so that we can send you the blood and urine test result. The information will be used by ATSDR scientist to link the results with each individual and send the blood and urine test results to you.

When can we ask questions?

If you have any questions about this testing, you can ask us now If you have questions later, you can call: Dr. Lourdes Rosales-Guevara at 770-488-0744 or Cell: 404-272-8902 Or at the ATSDR toll free number 1-888-320-5291

Voluntary Consent

I agree to be tested I have been given the chance to ask questions and feel my questions have been answered I know that having these tests done is my choice I know that even though I have agreed to this testing, I may leave it at any time without penalty

Signature

I give my permission for my daughter to be tested

____________________________ __________________

Signature of Person Given Consent Date

Age _________

Address _____________________________

______________________________

______________________________

Telephone__________________

May we share this test results with other federal or state health and

environmental agencies? YES_____________, NO____________

Lab ID Number____________________

Certification of Consent Form Administrator:

I have read the consent form to the person name above. They have had the opportunity to ask questions about the EI and had the questions answered.

_______________________________________