ATSDR Child Assent

Appendix D4: Assent Form for Children between 6 and 17 Years of Age

Flesch-Kincaid Reading level – 6.6

Assent Form for Blood Lead Testing

Children between 6 and 17 years of age

ATSDR Exposure Investigation (EI)

Jasper and Newton Counties, MO

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 7 Environmental Protection Agency (EPA)

• Missouri Department of Health and Senior Services (MDHSS)

• Your local public health departments

Why we are doing this Exposure Investigation (EI)?

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

• We are testing lead in blood samples

• Although not in our target population, ATSDR will also evaluate BLLs for minor siblings of participants ≥ 72 months, if requested by a parent or guardian, as a public health service to the community.

• Your parent or guardian requested that we measure your blood lead.

• Siblings of participants between 6 and 17 years of age will not be compensated, and their results will not be included as part of the EI report.

What are we asking you to do?

• You are invited to have your blood tested for lead.

• There is NO COST to you or your parents for the testing.

• Allow a licensed phlebotomist to take a sample of your blood.

What is included in my participation?

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.

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

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

• The lab will throw out any leftover blood.

When will you get the test results?

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

What are the benefits of being in this EI?

• You and your parents will know the levels of lead in your blood.

• If you are found to have high levels of lead, ATSDR will recommend you follow-up with your physician and will provide you with information that will help you reduce contact with lead.

What are the risks of this EI?

• The needle stick might hurt a little.

• Some bruising may happen where the blood is taken.

• You may feel a little lightheaded for a short time.

How will we protect your 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

Child Assent

• Your parent/guardian said it is all right for you to have the blood tests.

• Your parent/guardian said it is all right for you to answer some questions.

• You don’t have to have these tests or answer questions if you don’t want to.

Voluntary Assent

• I agree to be tested.

• I agree to answer questions.

• I was given the chance to ask questions and 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 agree to be tested and to answer questions.

_________________________________________ ___________ ______________

Printed name of child Age of child Sex of child

______________________________________________ __________________

Signature or written name of child in child’s handwriting Date

__________________________

Printed name of parent/guardian

Address of child ______________________________ Telephone __________________

______________________________

______________________________

Lab ID Number____________________

Certification of Assent Form Administrator:

I read the assent 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 assent