Form 5 Attach 17A Buccal Missing Script

OMB NO.: 0925-0406

EXPIRATION DATE: 10/31/2011

Attachment 17A:

Phase III Buccal Cell Missing Consent Form Script

Agricultural Health Study

Missing Buccal Cell Consent Forms

Public reporting burden for this collection of information is estimated to average five minutes per response, including the time for reviewing instructions, searching existing data sources, gathering and maintaining the data 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: NIH, Project Clearance Branch, 6705 Rockledge Drive, MSC 7974, Bethesda, MD 20892-7974, ATTN: PRA (0925-0406).  Do not return the completed form to this address.

Script

This is _______ at the University of Iowa. May I please speak to Mr./Ms.___________________?

I’m calling about the buccal cell sample that you sent in for the Agricultural Health Study in (mo/yr). Thank you for doing this for us . . . we really appreciate it.

The reason I’m calling (today/tonight) is because we didn’t get a signed consent form along with the sample you sent. We have a strict policy that won’t allow us to use your sample without a signed consent form from you. Do you have any questions or concerns about the form that I can answer?

I’ll go ahead and send out a new consent form so that you can read it over and sign it. We’ll include a postage-paid return envelope so you can send it back to us. Is your address still (cohort member’s address)?

<IF ADDRESS IS INCORRECT, PLEASE UPDATE IT ON CALL SHEET>

Thanks again for all your help with the study.