Parental Permission Form for Venous Blood Sampling for Lead and Questionnaire - Children Less Than 18 Years of Age

Attachment 3A: Parental Permission Form for Children less than 18 Years of Age

Flesch-Kincaid Reading level – 5.5

Parental Permission Form for Venous Blood Sampling for Lead

& Questionnaire

Children less than 18 years of age

ATSDR Exposure Investigation (EI)

Iola, Kansas

Who are we?

• We are from a federal public health agency, the Agency for Toxic Substances and Disease Registry (ATSDR),

Who are we working with?

• Region 7 Environmental Protection Agency (EPA)

• Kansas Department of Health and the Environmental (KDHE)

• South Eastern Kansas Multi County Health Department (SEKMCHD) and

• Region 7 Pediatric Environmental Health Specialty Unit (PEHSU)

Why we are doing this Exposure Investigation (EI)?

• We are doing this EI to find out if children living in Iola, Kansas, have high levels of lead in their blood.

• EPA has been conducting soil testing for lead. We would like to share this child blood lead testing data with EPA to help them identify families and homes that need soil cleanup the most.

What do we want you to do?

• Your child is invited to have his/her venous blood tested for lead.

• There is NO COST to you for the testing of your child.

• The blood collection will take place at _____________________.

What is included in my child’s participation?

There are two parts to your child’s participation.

1. Venous Blood Collection and Testing for Lead

• We will collect less than 1 teaspoon (3 milliliters) of blood from a vein of your child’s arm.

• This will take 10 minutes or less.

• We will send your child’s blood to a lab to test it for lead.

2. Answer a Short Questionnaire:

• We will ask you some questions about how your child might be exposed to lead.

• This should take about 20 minutes.

What will happen to any leftover blood after testing is finished?

• The blood will not be used or tested for anything else.

• The lab will throw out any leftover blood.

When will you get the test results?

• You will get your child’s test results by mail about 12 weeks after testing.

What are the benefits of being in this EI?

• You will know if your child has a high level of lead in blood.

• If your child has a blood lead level that is ≥5 µg/dL, ATSDR and Region 7 PEHSU can provide you with information that will help you reduce your child’s contact with lead and recommend follow-up with a doctor.

• If your child has a blood lead level ≥10 µg/dL, it will be reported to the KDHE, as required by law. Also, EPA will cleanup your yard faster if they know about high lead levels in both your soil and in your child’s blood.

What are the risks of this EI?

• Your child might cry because the needle hurts.

• Your child’s arm may be bruised where the blood is taken from.

• Your child may feel dizzy or lightheaded.

How will we protect your privacy?

• We will protect your child’s privacy as much as the law allows.

  • Kansas law requires that we report blood lead levels to KDHE if the result is 10 µg/dL or higher.

  • Kansas law requires that information given to the state may be made public if someone asks them for the information, but your child’s name and address will not be released.

  • We will share the results with other agencies only with your permission. We will require our government partners to treat your information as private.

• We will give your child an identification (ID) number.

  • Your child’s ID number, not his/her name, will go on the tube of blood.

  • We will keep a record, under lock-and-key, of your child’s name, address and ID number. We will use this information to link your child’s results with his/her name so we can send you your child’s test results.

• We will not use your or your child’s name in any report we write. Only group information that does not include individual names will be reported.

When can you ask questions about the testing?

• If you have any questions about this testing, you can ask us now.

• If you have questions later, you can call:

  • Dr. Luly Rosales-Guevara at (770) 488-0744 or 

  • The Iola Exposure Investigation toll free number (888) 892-1320

Parental/Guardian Voluntary Permission

• I agree to have my child tested.

• I agree to answer questions about my child.

• I was given the chance to ask questions on behalf of my child. I feel my questions have been answered.

• I know that having these tests done is my choice.

• I know that even though we agreed to this testing, my child may leave at any time without penalty.

1. Regardless of the results, may we share the test result with other federal, state, and local health and environmental agencies? YES / NO (please circle one)

2. If the results are 5 and up to 10 µg/dL, can we provide your information to the Pediatric Environmental Health Specialty Unit (PEHSU), and may they contact you for follow-up? YES / NO (please circle one)

3. If the results are ≥10 µg/dL, we are required to report it to KDHE. Can we also provide your child’s results to PEHSU for follow-up? YES / NO (please circle one)

Signature

I give permission for my child to be tested and agree to answer questions about my child.

______________________________________ ______ ___________

Printed name of child Age Sex of child

___________________________________ __________________

Signature of parent/guardian Date

___________________________________

Printed name of parent/guardian

Address of Child _____________________________ Telephone __________________

______________________________

______________________________

Lab ID Number____________________

Certification of Permission Form Administrator:

I read the permission form to the person named above. He/she had the opportunity to ask questions about the Exposure Investigation and had the questions answered.

_______________________________________

Signature of person administering permission