Parental Permission Form - Children Younger than 18 Years of Age

Att3C_Parental Permission Form_Anaconda EI_0923-0048.docx

ATSDR Exposure Investigations (EIs)

Parental Permission Form - Children Younger than 18 Years of Age

OMB: 0923-0048

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Attachment 3C: Parental Permission Form for Children younger than 18 Years of Age

Flesch-Kincaid Reading level – 7.4


Parental Permission Form for Blood and Urine Testing

Children younger than 18 years of age

ATSDR Exposure Investigation (EI)

Anaconda, Montana


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 8 Environmental Protection Agency (EPA)

    • Anaconda Deer Lodge County (ADLC) Health Department

    • Montana Department of Public Health and Human Service (MDPHSS)


Why we are doing this Exposure Investigation (EI)?

  • We are doing this EI to respond to community concerns about lead and arsenic in the environment and to help people find out if they are exposed

  • We are testing lead in blood samples and arsenic in urine samples

What do we want you to do?

  • Your child/ward is invited to have his/her blood tested for lead and urine tested for arsenic.

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

  • Collect your child’s/ward’s urine sample at home and bring it to the blood collection location.

  • Complete a brief questionnaire with that will ask questions regarding how your child/ward may be exposed to lead and arsenic.

  • Allow a licensed phlebotomist to take a sample of your child’s/ward’s blood.


What is included in my child’s/ward’s participation?

There are three parts to your participation.

  1. Urine Collection and Testing for Arsenic

    1. The first morning urine sample from your child/ward that you collected at home and froze was brought to the blood testing location.

    2. We will send your child’s/ward’s urine to a lab to test it for arsenic.

    3. The urine will not be tested for drugs, alcohol or HIV.

  2. Answer a Short Questionnaire

    1. We will ask you some questions about your home and how your child/ward might be exposed to lead and arsenic.

    2. This should take about 20 minutes.

  3. Blood Collection and Testing for Lead

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

    • This will take 10 minutes or less.

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

    • The blood will not be tested for drugs, alcohol or HIV.

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

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

  • The lab will throw out any leftover blood and urine.


When will you get the test results?

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


What are the benefits of being in this EI?

  • You will know the levels of lead in the blood and arsenic in the urine of your child/ward.

  • If your child/ward is found to have high levels of lead or arsenic, ATSDR and ADLC will recommend you follow-up with your child’s/ward’s physician and will provide you with information that will help you reduce contact with lead and arsenic.


What are the risks of this EI?

  • The needle stick might hurt a little.

  • Some bruising may happen where the blood is taken.

  • Your child/ward may feel a little lightheaded for a short time.


How will we protect your child’s/ward’s privacy?

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

    • Montana law requires that we report blood lead levels to the ADLC if the result is greater than 5 µg/dL.

    • Montana law requires that information given to the state may be made public if someone asks them for the information but your 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/ward an identification (ID) number.

    • Your child’s/ward’s ID number, not their name, will go on the tube of blood and urine sample.

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

  • We will not use your child’s/ward’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

    • Dr. Matt Karwowski at 404-718-5867

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


Parental/Guardian Voluntary Permission

  • I agree to have my child/ward tested.

  • I agree to answer questions about my child/ward.

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

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

  • I know that even though we agreed to this testing, my child/ward 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)



    1. If the results are 5 µg/dL or greater, 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)



Signature


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


______________________________________ ______ ___________

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






File Typeapplication/vnd.openxmlformats-officedocument.wordprocessingml.document
AuthorScruton, Karen M. (ATSDR/DCHI/SSB)
File Modified0000-00-00
File Created2021-01-20

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