Form 0920-1173 Screening Survey

Attachment C

Screening Survey

Form Approved

OMB No. 0920-1173

Exp. Date 03/31/2020

Screening Survey

Exposure to Arsenic and Uranium in Private Well Water in Connecticut, New Mexico, and New Hampshire

Time interview began: _ _: _ _ AM / PM Date ___________

Name of Respondent: _____________________ _____________________________

Last Name First Name MI

Mailing/Telephone information (label):

Additional Contact information

Subject Name, ID, Collection Checklist

First name(s)
Subject form labels	Subject Form Label 1

CDC estimates the average public reporting burden for this collection of information as 30 minutes per response, including the time for reviewing instructions, searching existing data/information sources, gathering and maintaining the data/information needed, and completing and reviewing the collection of information. An agency may not conduct or sponsor, and a person is not required to respond to a collection of information unless it displays a currently valid OMB control number. Send comments regarding this burden estimate or any other aspect of this collection of information, including suggestions for reducing this burden to CDC/ATSDR Information Collection Review Office, 1600 Clifton Road NE, MS D-74, Atlanta, Georgia 30333; ATTN: PRA (0920-1173).

Hello,

My name is <name> and I am calling as a representative of your <state, department>.

The <state, department> is working with The U.S. Geological Survey (USGS) and the National Center for Environmental Health (NCEH), Centers for Disease Control and Prevention to understand exposure to arsenic and uranium from private well water.

<State> has told us that there is no information about arsenic and/or uranium in well water in your area of the state. We want to test for the amount of arsenic and uranium in the water from 100 wells in your area. We also would like to know how arsenic and uranium in private well water is related to arsenic and uranium in people’s urine, so we will also collect a tap water sample and ask one adult in your household to give us a urine specimen and answer some questions.

Your participation in this investigation will greatly enhance our understanding of where arsenic and uranium are in the ground water that supplies private wells. Are you willing to volunteer for the investigation?

If no: OK. Thank you.

If yes: Thank you very much.

I need to ask you a few more questions to make sure you are eligible to be in the investigation:

Yes No (check correct box)

□ □ Are you at least 18 years old?

□ □ Do you live in a household with a domestic private well?

□ □ Are you currently pregnant?

□ □ Do you know whether you well water is treated before it is used in the home?

□ □ Do you use the water for drinking and cooking?

□ □ Will you allow investigation representatives to collect 2 well water samples (raw water from the well and tap water)?

□ □ Are you willing to provide a urine specimen?

□ □ Are you willing to complete a survey?

<if all questions are yes except for the pregnancy question> Thank you. You are eligible to be in the investigation!

We will send you a copy of the investigation consent form, a urine cup to collect a first morning void specimen, and instructions for collecting the sample. We will bring a consent form for you to sign and the survey when we visit your home to collect the water and urine samples.

<if otherwise> Thank you, but I am sorry, we need people to (choose appropriate option) <be 18 years old OR live in a household with a private well OR not currently be pregnant OR know whether their drinking water is treated OR use the water for drinking and cooking OR allow us to collect water samples OR provide urine specimen> to be in our investigation.

OK, let’s go ahead and set up an appointment for us to do our investigation activities.

For well water and tap water sampling, urine collection, and survey administration: We’ll need about an hour to collect the water samples and urine and do the survey. We would like to collect your first morning urine, so I would like to send you a urine specimen cup for you to use on the day we come to your home for the water samples and to do the survey.

Can you give me some good times between <date> and <date> when we can come to your home?

Possible dates and times:

Date	Time

Thank you. We have time to come to your home on <date> at <time>. Will that be OK?

If yes: Thank you very much.

If no: Try another date and time.

Thank you. We will call you the day before to remind you that we will be coming to your home.