Privacy Act Statement

Attachment 3: Privacy Act Statement and Consent Forms

3A: Privacy Act Statement

3B: Adult Consent Form for Blood and Urine Testing

3C: Parental Permission Form for Blood and Urine Testing: Children younger than 18 years of age

3D: Assent Form for Blood and Urine Testing: Children between 7 and 17 years of age

PRIVACY ACT STATEMENT

FOR

Anaconda, Montana Exposure Investigation II – Blood Lead and Urine Arsenic Testing

This statement provides the notice required by the Privacy Act of 1974 (5 USC § 552a(e)(3)).

• Authority: The Agency for Toxic Substances and Disease Registry (ATSDR) has the authority to collect this information under the ‘‘Comprehensive Environmental Response, Compensation, and Liability Act of 1980’’ (CERCLA) as amended by ‘‘Superfund Amendments and Reauthorization Act of 1986’’ (SARA) (42 U.S.C. 9601, 9604).

• Purpose: ATSDR is conducting this investigation to assess your exposure to lead and arsenic in the Anaconda community as a result of past smelter activities. ATSDR is collecting this information on you or your child/ward for:

  • Adult consent or parental permission and child assent to participate in questionnaires, and blood and urine collections.

  • Sending your or your child’s/ward’s testing results back to you.

• Routine Uses:

  • ATSDR may disclose these records to the local health department to provide follow-up, as needed, for blood lead results.

  • Other routine uses as described in Statement of Records Notice (SORN) No. 09-19-0001 - ‘‘Records of Persons Exposed or Potentially Exposed to Toxic or Hazardous Substances.” See https://www.gpo.gov/fdsys/pkg/FR-2011-01-25/pdf/2010-33004.pdf.

• Disclosure: Providing this information is voluntary. ATSDR needs this information for you or your child/ward to take part in the investigation. ATSDR may not include incomplete records in the data analysis. ATSDR needs up-to-date contact information to send your or your child’s/ward’s study results.