ATSDR Parental Permission

Appendix D3: Parental Permission Form for Blood Testing

Parental Permission Form for Blood Lead Testing

Children under 6 years of age

ATSDR Exposure Investigation (EI)

Jasper and Newton Counties, MO

Who are we?

• We are from a federal public health agency called the Agency for Toxic Substances and Disease Registry or ATSDR.

Who are we working with?

• Region 7 Environmental Protection Agency (EPA)

• Missouri Department of Health and Senior Services (MDHSS)

• Your local public health departments

Why are we doing this Exposure Investigation?

• We are doing this EI to try to better understand lead levels in your blood and your environment and how they are related.

What are we asking you to do?

• Allow a licensed phlebotomist to take a sample of your child’s/ward’s blood and have it tested for lead by ATSDR.

• Have the soil in your child’s/ward’s yard and private well water tested by EPA.

• Have your dust, paint, and public water supply tested by MDHSS.

• Complete a brief questionnaire that will ask questions to help us understand how your child/ward might be exposed to lead.

• There is NO COST to you for any of the testing and each participating child/ward will receive a $20 cash gift card as a token of our appreciation for their participation.

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

There are three parts to your child’s/ward’s participation.

1. Blood Collection and Testing for Lead

• A licensed phlebotomist 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.

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

• The blood will only be tested for lead. It will not be used for any other purposes and will not be tested for other things such as drugs, alcohol, diseases, or DNA.

2. Answer a Short Questionnaire

• We will ask you some questions to better understand how your child/ward might be exposed to lead in and around your household.

• This should take about 20 minutes.

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

• The lab will properly dispose of any leftover blood.

When will you get the test results?

• You will get your blood lead and environmental test results by mail about 12 weeks after all samples have been analyzed. If your child/ward has a blood level greater than 3.5 ug/dL or if you have a blood lead level > 5 µg/dL, ATSDR’s medical officer will contact you by phone as soon as the results are received from the laboratory.

What are the benefits of being in this EI?

• You will know the levels of lead in your child’s/ward’s blood, soil, water, and household.

• If your child/ward is found to have high levels of lead in their blood compared with most children, we will recommend you follow-up with your physician and we will provide information that will help you reduce your contact with lead. You may have a follow-up investigation performed by the state or county.

• If high levels of lead are found in your child’s/ward’s yard, you may be eligible for EPA to remove lead contaminated materials from your child’s/ward’s yard.

• If high levels of lead are found in your child’s/ward’s private drinking water well, you may be eligible for EPA to provide a clean source of water.

• If high levels of lead are found in your paint or lead is found in your water from your pipes, MDHSS and ATSDR will provide information that will help you reduce your child’s/ward’s contact with lead in your paint and water.

What are the risks of the EI?

• Your child/ward may feel a sharp sting from the needle used to draw their blood. Sometimes a bruise or small blood clot can occur where the blood is taken. These bruises or clots usually go away on their own.

• Your child/ward may feel lightheaded for a short time and rarely, fainting may occur.

• Although it is rare, infection could develop as a result of the puncture through the skin, or the needle could irritate or injure a nerve. This irritation may cause temporary numbness or pain in part of the arm.

• If your child/ward has a history of anemia, a bleeding disorder, or is taking blood thinning medication, we recommend that you talk to your child’s/ward’s doctor before joining this study.

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

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

  • Missouri law requires that we report blood lead levels to the state.

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

  • We will share the results between the agencies, with your permission. We will require our government partners to treat your child’s/ward’s information as private.

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

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

  • We will keep a record secured by password or 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 child/ward and the results will be sent to you.

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

When can you ask questions about the testing?

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

• If you have questions later, you can call or email:

  • ATSDR

    • Commander (CDR) Erin Evans at 913-551-1311 or isb5@cdc.gov

    • Dr. Michelle Zeager at 470-727-6081 or pqr5@cdc.gov for medical questions

    • The Jasper and Newton Counties Exposure Investigation toll free number 833-678-2724 or MOLead@cdc.gov

Other considerations:

• If lead is found in your soil, water, or household, you may have to disclose this when you go to sell or lease your home in the future.

Voluntary Consent:

• I agree to have my child/ward tested.

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

• I know that having the test done is my choice.

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

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

Signature

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

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Printed name of child/ward	Sex of child/ward	Age
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Signature of parent/guardian	Date
_________________________________________________
Printed name of parent/guardian
ADDRESS of child/ward: ______________________________
_________________________________________________
_________________________________________________
PHONE: ________________________________________
Lab ID Number: __________________________________

Certification of Permission Form Administrator:

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

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Signature of person administering form	Date