Consent Form for Adults Aged 18 years and Over

Attachment 3C: Consent Form for Adults Aged 18 years and Over

Flesch-Kincaid Reading level – 5.2

Follow Up Biologic Testing for Exposure to Arsenic

ASARCO Hayden Smelter Site, Hayden & Winkelman, Arizona Exposure Investigation

Consent Form for Urine Arsenic Testing and Questionnaire

Adults Aged 18 years of age and over

Who are we?

• We are from a federal public health agency, the Agency for Toxic Substances and Disease Registry (ATSDR), and the Arizona Department of Health Services (ADHS).

Why we are doing this Exposure Investigation?

• We are doing this Exposure Investigation to find out if adults living in Hayden or Winkelman, AZ, have high levels of arsenic in their urine.

What are we asking you to do?

• You are invited to have your your urine tested for arsenic.

• There is NO COST to you for the testing.

Place for Blood and Urine Collection

• The urine collection will take place in your home or at XXX.

What is included in my participation?
There are three parts to your participation.

1. Urine Collection and Testing for Arsenic

• The urine can be collected in your home or at the urine collection facility.

• Collect your urine in a plastic cup we give you. Put the lid on.

• Write your name on the label on the side of the cup.

• Put the cup in a zip lock bag in the refrigerator until you bring it to XXX.

• It should take 5 minutes or less for you to collect your urine.

• We will send your urine to a lab to test it for arsenic.

2. Answer a Short Questionnaire

• We will ask you some questions. It will take about 20 minutes.

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

• The lab will throw out any leftover urine. It will not be used for anything else.

When will you get the test results?

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

What are the benefits from being in this Exposure Investigation?

• You will know if you have high level of arsenic in your urine.

• If you a high urine arsenic level, ATSDR and ADHS will provide you with information that can help you reduce your contact with arsenic.

What are the risks of this EI?

• There is no risk from collecting urine.

How will we protect your privacy?

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

  • Arizona law requires that information given to the state may be made public if someone asks them for the information.

• We will give you an identification (ID) number.

  • Your ID number, not your name, will go on the urine cup.

  • We will keep a record, under lock-and-key, of your name, address, and ID number. The information will be used by ATSDR scientists to link the results to each person and send your blood and urine test results to you.

• We will not use your 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. Bruce Tierney at 770-488-0771 

  • 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 I 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 Giving Consent Date Age

Address _____________________________ Telephone __________________

______________________________

______________________________

May we share the test results with other federal, state, and local health and environmental agencies? YES / NO (please circle one)

Lab ID Number____________________

Certification of Consent Form Administrator:

I read the consent 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 the consent