Authorization & Study Letters

Authorization Letters.docx

Children's Health after the Storms (CHATS)

Authorization & Study Letters

OMB: 0920-0925

⚠️ Notice: This form may be outdated. More recent filings and information on OMB 0920-0925 can be found here:

2012-04-17 - No material or nonsubstantive change to a currently approved collection

Document [docx]

Download: docx | pdf

ATTACHMENT T

Authorization Letters

ATTACHMENT T1

Field Interviewer Authorization Letter

FIELD INTERVIEWER AUTHORIZATION LETTER

[DATE]

To Whom It May Concern:

This letter certifies that «Fname» «Lname» is a representative for the Children’s Health after the Storms (CHATS) study, sponsored by the Centers for Disease Control and Prevention (CDC). RTI International (RTI), a nationally recognized not-for-profit research organization with headquarters in Research Triangle Park, North Carolina, is under contract to the Federal Government to perform all data collection activities associated with the survey (CDC Contract Number: 200-2010-34803).

Field Interviewers working on this study have been individually hired and trained by RTI staff to work specifically on this project between the dates of XXX, X, XXX through XXX, X, XXXX.

If you need additional assurance that «Fname» «Lname» is a legitimate RTI representative assigned to this government sponsored study, please contact XXX, [insert name and project title], toll-free at 1-800-XXX-XXXX, extension ____, or the toll free project hotline at 1-XXX-XXX-XXXX, between 9:00 AM and 5:00 PM CST, Monday through Friday.

Thank you for your cooperation.

S incerely,

Diane Wagener, PhD.

Project Director

Children’s Health after the Storms

ATTACHMENT T2

Registered Nurse Authorization Letter

REGISTERED NURSE AUTHORIZATION LETTER

[DATE]

To Whom It May Concern:

This letter certifies that «Fname» «Lname» is a trained Registered Nurse for the Children’s Health after the Storms (CHATS) study, sponsored by the Centers for Disease Control and Prevention (CDC). RTI International (RTI), a nationally recognized not-for-profit research organization with headquarters in Research Triangle Park, North Carolina, is under contract to the Federal Government to perform all data collection activities associated with the survey (CDC Contract Number: 200-2010-34803).

Registered Nurses working on this study have been individually hired from local public health care providers and trained by RTI staff to work specifically on this project between the dates of XXX, X, XXXX through XXX, X, XXXX.

If you need additional assurance that «Fname» «Lname» is a legitimate Registered Nurse working on behalf of RTI and assigned to this government sponsored study, please contact XXX, [insert project name and title], toll-free at 1-800-XXX-XXXX, extension ____, or the toll-free project hotline at 1-XXX-XXX-XXXX, between 9:00 AM and 5:00 PM CST, Monday through Friday.

Thank you for your cooperation.

Sincerely,

Diane Wagener, PhD.

Project Director

Children’s Health after the Storms

ATTACHMENT T3

Medical Records Abstractor

Authorization Letter

MEDICAL RECORDS ABSTRACTOR AUTHORIZATION LETTER

[DATE]

To Whom It May Concern:

This letter certifies that «Fname» «Lname» is a medical records abstractor working on the Children’s Health after the Storms (CHATS) study, sponsored by the Centers for Disease Control and Prevention (CDC). RTI International (RTI), a nationally recognized not-for-profit research organization with headquarters in Research Triangle Park, North Carolina, is under contract to the Federal Government to perform all data collection activities associated with the survey (CDC Contract Number: 200-2010-34803).

Medical record abstractors working on this study have been hired and trained by RTI staff to work specifically on this project between the dates of XXX, X, XXX through XXX, X, XXXX.

If you need additional assurance that «Fname» «Lname» is a legitimate representative working on behalf of RTI and assigned to this government sponsored study, please contact XXX, [insert name & project title], toll-free at 1-800-XXX-XXXX, extension ____, or the toll free project hotline at 1-XXX-XXX-XXXX, between 9:00 AM and 5:00 PM CST, Monday through Friday.

Thank you for your cooperation.

S incerely,

Diane Wagener, PhD.

Project Director

Children’s Health after the Storms

ATTACHMENT U

Sorry I Missed You Card

SORRY I MISSED YOU CARD

Children’s Health after the Storms (CHATS)

Front of Card:

Sorry I Missed You

Back of Card:

RTI International

Survey Research Division

P. O. Box 12194

Research Triangle Park, NC 27709
1 (800) XXX-XXXX

Inside of Card (upper portion): blank

Inside of Card (lower portion):

Date: _____/_____/_____

Time: _________

Dear Resident:

I stopped by today to talk to you about an important research study being conducted by RTI International.

I am sorry that I did not find you at home. I will return to talk with you in the next few days. Thank you in advance for your participation.

Sincerely, ____________________________

ATTACHMENT V

Unable to Contact Letter

UNABLE TO CONTACT LETTER - SCREENING

[DATE]

Resident

[STREET ADDRESS]

[CITY], [STATE] [ZIPCODE]

Dear Community Member:

Recently, an interviewer from RTI International attempted to contact your household about taking part in the Children’s Health after the Storms (CHATS) study. This study is supported by the Centers for Disease Control and Prevention (CDC). So far, we have been unable to speak with anyone in your household. Your participation in this study is important—this is why we continue to try and reach you.

Some people are careful about speaking to a stranger at their door, and this is understandable. Please know that we are not selling anything. We just have a few general questions to ask that will take about 10 minutes of your time. You do not even need to let the interviewer into your home. You can answer the questions right at your door.

Based on your answers, a child in your home may be selected to take part in our study. It is also possible that no one will be selected to participate. As a thank you for your time, your household could receive up to $140 in cash depending on the age of our child, and the study parts in which your family qualifies.

The purpose of the Children’s Health after the Storms Study is to find out if children who lived in Federal Emergency Management Agency (FEMA)-supplied trailers after Hurricanes Katrina and Rita have any special health issues. In order to accomplish our goal, it is very important that we also speak to children who did not live in any of the FEMA-supplied trailers during that time. This is so that we can compare the health of the two groups of children. A limited number of households were randomly selected to represent this large population of Gulf Coast children, and as a result, we cannot invite another household to participate.

I have included with this letter a brochure with more information about CHATS. I hope that after reading it you will agree to take part in this important study. One of our interviewers will call on you again soon. If you have any questions or concerns, or would like to set up an appointment, please call me toll-free at 1-800-334-8571, extension 5628 from 9 am - 5 pm CST. Thank you very much for your time.

S incerely,

Diane Wagener, PhD

Project Director

Children’s Health after the Storms

ATTACHMENT W

Refusal Letters

ATTACHMENT W1

General Refusal Letter

GENERAL REFUSAL CONVERSION LETTER

[DATE]

[Parent Name]

[STREET ADDRESS]

[CITY], [STATE] [ZIPCODE]

Dear [Parent Name],

Recently, an interviewer from RTI International came to your home and asked permission for your child to take part in the Children’s Health after the Storms (CHATS) study. This study is supported by the Centers for Disease Control and Prevention (CDC). At that time, you did not wish for your child to take part in the study. I am writing to tell you more about the study and hope you will reconsider.

The purpose of the Children’s Health after the Storms study is to find out if children who lived in Federal Emergency Management Agency (FEMA)-supplied trailers after Hurricanes Katrina and Rita have any special health issues. In order to accomplish our goal, it is very important that we also speak to children who did not live in any of the FEMA-supplied trailers during that time. This is so that we can compare the health of the two groups of children.

Your participation is critical to the success of our study. A small number of children were randomly selected to represent children living on the Gulf Coast. Your child cannot be replaced. If your child does not take part in the study, the health experiences of children like yours will not be heard. By participating in this study, your child will help us record the experiences, symptoms and illnesses among these children.

We understand that the privacy of your family is important, and we will keep all information your family provides strictly private. You and your child can refuse to answer any questions you do not want to answer. Any services you and your family may receive will not be affected as a result of your participation. All answers and data collected for CHATS will be combined with other interviews and provided to the public in summary form only and your names will not be included in these reports.

In addition, RTI has obtained a Federal Certificate of Confidentiality which prevents the release of your names or other identifying characteristics to anyone not connected with the CHATS study. There is an important exception: If the CHATS interviewer or nurse feels that a participant’s life or health is in danger, they will inform the appropriate county or state agency.

As a thank you for your time, your household could receive up to $140 depending on the age of your child and the study parts in which your family qualifies.

I have included with this letter a brochure with more information about CHATS. I hope that after reading it you will agree to have your child take part in this important study. You and your child can make a difference, but only if you participate. One of our interviewers will call on you again soon. If you have any questions or concerns, or would like to set up an appointment, please call me toll-free at 1-800-334-8571, ext. 5628 from 9 am - 5 pm CST. Thank you very much for your time.

S incerely,

Diane Wagener, PhD

Project Director

Children’s Health after the Storms

ATTACHMENT W2

Anti-Government Refusal Letter

REFUSAL LETTER – ANTI-GOVERNMENT

[DATE]

[Resident]

[STREET ADDRESS]

[CITY], [STATE] [ZIPCODE]

Dear Community Member,

Recently, an interviewer from RTI International came to your home and asked your household to take part in the Children’s Health after the Storms (CHATS) study. At that time, you were concerned about your family participating in a study sponsored by the federal government. I am writing to tell you more about the study and hope you will reconsider.

CHATS is supported by the Centers for Disease Control and Prevention (CDC). RTI International, a not-for-profit research organization, is carrying out the study on CDC’s behalf. The purpose of the Children’s Health after the Storms study is to find out if children who lived in Federal Emergency Management Agency (FEMA)-supplied trailers after hurricanes Katrina and Rita have any special health issues. In order to accomplish our goal, it is very important that we also speak to children who did not live in any of the FEMA-supplied trailers during that time. This is so that we can compare the health of the two groups of children.

Your participation is critical to the success of our study. A small number of households were randomly selected to represent the children living on the Gulf Coast. Your household cannot be replaced. If your household does not take part in the study, the health experiences of children like yours will not be heard. By participating in this study, you will help us to record the experiences, symptoms and illnesses among these children.

We understand that the privacy of your family is important, and we will keep all the information your family provides strictly private. You can refuse to answer any questions you do not want to answer. Any services you and your family may receive will not be affected as a result of your participation. The CDC will not receive your names or address nor will any other government agency. All answers and data collected for CHATS will be combined, all published information about the study will be in summary form only and your names will not be included in these reports. All RTI employees are required by law to safeguard and protect the information collected for the CHATS study.

As a thank you for your time, your household could receive up to $140 depending on the age of your child and the study parts in which your family qualifies.

I have included with this letter a brochure with more information about CHATS. I hope that after reading it you will agree to take part in this important study. Your household can make a difference, but only if you participate. One of our interviewers will call on you again soon. If you have any questions or concerns, or would like to set up an appointment, please call me toll-free at 1-800-334-8571, extension 5628 from 9 am - 5 pm CST. Thank you very much for your time.

S incerely,

Diane Wagener, PhD.

Project Director

Children’s Health after the Storms

ATTACHMENT X

Study Results

ATTACHMENT X1

Normal Range Health Assessment Results Letter

NORMAL RANGE HEALTH ASSESSMENT RESULTS LETTER

[DATE]

[ID]

[Name]

[Address]

[City, St. Zip]

Dear [NAME]:

Thank you very much for taking part in the Children’s Health after the Storm (CHATS) study. As promised, we are sending you the results of the laboratory tests on your child’s blood and urine as well as an explanation of these results.

All of your child’s test results are within the range considered as normal. These results are highlighted on the second page of this letter. Please note that the health assessment your child received from the CHATS study nurse should not replace any scheduled visits to your regular doctor or health care provider.

We would also like to take this opportunity to reassure you that the information you and your child provided for the CHATS Study will be kept private and will be used only for research purposes. All published information about the study will be in summary form only; your names will not be in any report with the study’s results.

While we cannot give you medical advice, if you have questions about your results or want a list of local doctors and clinics, please call our lead nurse, [NAME], toll-free at 1-800-xxx-xxxx.

We will check in on you and your child again in several months to see how you are doing and to discuss the next phase of this important survey. We hope we can count on your continued support.

S incerely,

Diane Wagener, PhD.

Project Director

Children’s Health after the Storms

Results of your child’s blood and urine tests:

Test	Your Child’s Measurement	Normal Range
Hemoglobin¹	xxxx	xxxx to xxxx
White Blood Cells²	xxxx	xxxx to xxxx
Platelets ³	xxxx	xxxx to xxxx
Total IgEº	xxxx	xxxx to xxxx
IgE- (Cats)^	xxxx	xxxx to xxxx
IgE (Oak)*	xxxx	xxxx to xxxx
IgE (mold)	xxxx	xxxx to xxxx
Urinary creatinine'	xxxx	xxxx to xxxx

¹ Hemogloblin is the substance in blood that carries oxygen; measurements outside the normal range may be due to anemia or other blood conditions.

² White blood cells are associated with the body’s ability to fight infections; measurements outside the normal range may be due to an infection or the body trying to deal with an infection.

³ Platelets are the cells associated with blood clotting; measurements outside the normal range may be due to prolonged bleeding or other blood conditions.

º ^ *  Total IgE and specific IgEs (such as cats, oak tree, and mold) are substances, often called antibodies, that are part of the body’s reaction to exposures to things such as cats, tree dust and pollen, and mold; measurements higher than the normal range may be linked to allergies of those exposures.

' Urinary creatinine is a natural occurring substance in urine; an elevation in the level maybe associated with kidney problems.

ATTACHMENT X2

Abnormal Range Health Assessment Results Letter

ABNORMAL RANGE HEALTH ASSESSMENT RESULTS LETTER

[DATE]

[ID]

[Name]

[Address]

[City, St. Zip]

Dear [NAME]:

Thank you very much for taking part in the Children’s Health after the Storms (CHATS) study. As promised, we are sending you the results of the laboratory tests on your child’s blood and urine as well as an explanation of these results.

One or more of your child’s test results is outside of the normal range. These results are highlighted on second page of this letter. We suggest that you take this report and discuss the results with your health care provider as soon as possible. Please note that the health assessment your child received from the CHATS study nurse should not replace any scheduled visits to your regular doctor or health care provider

While we cannot give you medical advice, if you have questions about your report or want a list of local doctors and clinics, please call our lead nurse, [NAME], toll-free at 1-800-xxx-xxxx.

We will check in on you and your child again in several months to see how you are doing and to discuss the next phase of this important study. We hope we can count on your continued support.

S incerely,

Diane Wagener, PhD

Project Director

Children’s Health after the Storms

Results of your child’s blood and urine tests:

Test	Your Child’s Measurement	Normal Range
Hemoglobin¹	xxxx	xxxx to xxxx
White Blood Cells²	xxxx	xxxx to xxxx
Platelets ³	xxxx	xxxx to xxxx
Total IgEº	xxxx	xxxx to xxxx
IgE- (Cats)^	xxxx	xxxx to xxxx
IgE (Oak)*	xxxx	xxxx to xxxx
IgE (mold)	xxxx	xxxx to xxxx
Urinary creatinine'	xxxx	xxxx to xxxx

¹ Hemogloblin is the substance in blood that carries oxygen; measurements outside the normal range may be due to anemia or other blood conditions.

² White blood cells are associated with the body’s ability to fight infections; measurements outside the normal range may be due to an infection or the body trying to deal with an infection.

³ Platelets are the cells associated with blood clotting; measurements outside the normal range may be due to prolonged bleeding or other blood conditions.

' Urinary creatinine is a natural occurring substance in urine; an elevation in the level maybe associated with kidney problems.

ATTACHMENT X3

Session 2 Health Assessment Results

Child’s Name: Date:

Type of Assessment (check one): Baseline 6 month

Below are the results from your child’s health assessment. These are given to you for your personal records. These tests do not substitute for a visit to your own doctor or other health professional. We encourage you to share all of these results with your child’s doctor/healthcare provider especially if any of the results are outside the normal limits. We encourage you to let your child’s physician/healthcare provider know about any results that are outside the normal limits. If you or the child’s physician/healthcare provider has questions about these results, they can contact the CHATS Lead Nurse at xxx-xxx-xxxx.

1. Your child’s weight is: ______lbs

Within normal limits: ______ Outside normal limits: ______

2. Your child’s skin examination for evidence of allergic reaction is:

Within normal limits: ______ Outside normal limits: ______

3. Your child’s spirometry result (indication of lung function) is:

Within normal limits: ______ Outside normal limits: ______

4. Your child’s exhaled nitrous oxide results (indication of inflammation of the breathing system) is:

Within normal limits: ______ Outside normal limits: ______

Nurse’s Printed Name:

Nurse’s Signature:

ATTACHMENT X4

Extreme Value Health Assessment Results Letter

EXTREME VALUE HEALTH ASSESSMENT RESULTS LETTER

[DATE]

[ID]

[Name]

[Address]

[City, St. Zip]

Dear [NAME]:

Thank you very much for taking part in the Children’s Health after the Storm (CHATS) study.

As we promised, we are providing the results of your child’s laboratory tests. One or more of your child’s test results is outside of the normal range and may pose a serious health risk to your child. The result is outlined below in this letter.

We suggest that you take this report right away and discuss the results with your health care provider. Please note that the health assessment your child received from the CHATS study nurse should not replace any scheduled visits to your regular doctor or health care provider

Test Child’s value Normal Range

Xxxx xxxx xxx

While we cannot give you medical advice, if you have questions about your report or want a list of local doctors and clinics, please call our lead nurse, [NAME], toll-free at 1-800-xxx-xxxx.

We would also like to take this opportunity to reassure you that the information you and your child provided for the study will be kept private and will be used only for research purposes. Your names will not be in any report with the study’s results.

We will check in on you and your child again in several months to see how you are doing and to discuss the next phase of this important study. We hope we can count on your continued support.

S incerely,

Diane Wagener, PhD.

Project Director

Children’s Health after the Storms

ATTACHMENT X5

Normal Range Environmental Test Results Letter

ENVIRONMENTAL TEST RESULTS LETTER

Low Ambient/Normal Cotinine

[DATE]

[ID]

[Name]

[Address]

[City, St. Zip]

Dear [NAME]:

Thank you very much for taking part in the Children’s Health after the Storm (CHATS) study. As promised, we are sending you information about the air samples we took in and outside your home.

We tested particles in the air, nitrogen dioxide which is toxic gas, and smoke from tobacco. The U.S. Environmental Protection Agency has set National Air Quality Standards for nitrogen dioxide and particles in the air to protect public health, including health of children and people who have asthma. The levels of nitrogen dioxide and particles in the air in your home were below the Standards. This is good and means that appliances in your home such as gas ranges and ovens, gas water heaters, gas clothes dryers and any fireplaces are properly vented. It also means that any exhausts from cars or lawn mowers outside are not polluting the air inside your home. On the next page, we list the amount of nitrogen dioxide in your home and compare it against your community’s measurement and to the national standard. We also provided some website addresses and a brochure to help you lower the levels in your home even more.

It is important to understand that the amounts of these pollutants are estimates from measurements taken in your home over seven days. They do not fully describe your true exposure in your home and also outside of the home. Air pollutant amounts typically change on a daily basis. We have enclosed some information on air pollution, including specific information on these pollutants, where they tend to come from, and what you can do to decrease exposures for you and your child.

The U.S. Environmental Protection Agency does not have quality standards for exposure to tobacco smoke. However, the Environmental Protection Agency and Centers for Disease Control and Prevention encourage people not to smoke in the home and car because exposures can cause ear infections, more frequent and severe asthma attacks, coughing, shortness of breath, bronchitis, and pneumonia in children. On the next page, we also list the amount of cotinine in your child’s urine. The only way a child can have cotinine in the urine is if they are exposed to tobacco smoke. Although there are no government standards, we do have data on the levels of cotinine in children throughout the United States. Your child was within the normal range.

We would also like to take this opportunity to reassure you that the information you and your child provided for the CHATS study will be kept private and will be used only for research purposes. Your names will not be in any report with the study’s results.

If you have questions about your report, please call me toll-free at 1-800-xxx-xxxx. We will check in on you and your child again in several months to see how you are doing and to discuss the next phase of this important Study. We hope we can count on your continued support.

S incerely,

Diane Wagener, PhD.

Project Director

Children’s Health after the Storms

Reports from in and outdoor air samples (lower is better):

Pollutant	Your Household’s Measurement	Your Community’s Measurement	National Standard
PM10	xxxxx	xxxxx	xxxxx
Nitrogen Dioxide	Xxxxx	xxxxx	xxxxx
Tobacco Smoke	Xxxx	Not measured	None

Report of cotinine in the urine (lower is better)

Your Child’s Measurement Measurements in 90% of Children

Ages 3-11 Years Ages 12-19 Years

Less than 1.22 ng/mL Less than 1.16 ng/mL

List of websites:

ATTACHMENT X6

Abnormal Range #1 Environmental Test Results Letter

High Ambient/High Cotinine

ABNORMAL RANGE ENVIRONMENTAL TEST RESULTS LETTER

High Ambient/High Cotinine

[DATE]

[ID]

[Name]

[Address]

[City, St. Zip]

Dear [NAME]:

Thank you very much for taking part in the Children’s Health after the Storm (CHATS) study. As promised, we are sending you information about the air samples we took in and outside your home.

We tested particles in the air, nitrogen dioxide which is toxic gas, and smoke from tobacco. The U.S. Environmental Protection Agency has set National Air Quality Standards for nitrogen dioxide and particles in the air to protect public health, including health of children and people who have asthma. At least one of the levels of nitrogen dioxide and particles in the air in your home were above the Standards. This is means that appliances in your home such as gas ranges and ovens, gas water heaters, gas clothes dryers and any fireplaces are not properly vented. It also means that any exhaust from cars or lawn mowers outside may also be contributing to the air pollution inside your home. Poorly vented homes can lead to health problems. On the next page, we list the amount of nitrogen dioxide in your home and compare it against your community’s measurement and to the national standard. We also provided some website addresses and a brochure to help you lower the levels in your home.

S incerely,

Diane Wagener, PhD.

Project Director

Children’s Health after the Storms

Reports from in and outdoor air samples (lower is better):

Pollutant	Your Household’s Measurement	Your Community’s Measurement	National Standard
PM10	Xxxxx	xxxxx	xxxx
Nitrogen Dioxide	xxxxx	xxxxx	xxxxx
Tobacco Smoke	xxxxx	Not measured	None

Report of cotinine in the urine (lower is better)

Your Child’s Measurement Measurements in 90% of Children

Ages 3-11 Years Ages 12-19 Years

Less than 1.22 ng/mL Less than 1.16 ng/mL

List of websites:

ATTACHMENT X7

Abnormal Range #2 Environmental Test Results Letter

High Ambient/Normal Cotinine

ABNORMAL RANGE ENVIRONMENTAL TEST RESULTS LETTER

High Ambient/Normal Cotinine

[DATE]

[ID]

[Name]

[Address]

[City, St. Zip]

Dear [NAME]:

Thank you very much for taking part in the Children’s Health after the Storm (CHATS) study. As promised, we are sending you information about the air samples we took in and outside your home.

We tested particles in the air, nitrogen dioxide which is toxic gas, and smoke from tobacco. The U.S. Environmental Protection Agency has set National Air Quality Standards for nitrogen dioxide and particles in the air to protect public health, including health of children and people who have asthma. At least one of the levels of nitrogen dioxide and particles in the air in your home were above the Standards. This is means that appliances in your home such as gas ranges and ovens, gas water heaters, gas clothes dryers and any fireplaces are not properly vented. It also means that any exhaust from cars or lawn mowers outside may also be contributing to the air pollution inside your home. Poorly vented homes can lead to health problems. On the next page, we list the amount of nitrogen dioxide in your home and compare it against your community’s measurement and to the national standard. We also provided some website addresses and a brochure to help you lower the levels in your home.

It is important to understand that the amounts of these pollutants are estimates from measurements taken in your home over days. They do not fully describe your true exposure in your home and also outside of the home. Air pollutant amounts typically change on a daily basis. We have enclosed some information on air pollution, including specific information on these pollutants, where they tend to come from, and what you can do to decrease exposures for you and your child.

S incerely,

Diane Wagener, PhD.

Project Director

Children’s Health after the Storms

Reports from in and outdoor air samples (lower is better):

Pollutant	Your Household’s Measurement	Your Community’s Measurement	National Standard
PM10	Xxxxx	xxxxx	xxxx
Nitrogen Dioxide	xxxxx	xxxxx	xxxxx
Tobacco Smoke	xxxxx	Not measured	None

Report of cotinine in the urine (lower is better)

Your Child’s Measurement Measurements in 90% of Children

Ages 3-11 Years Ages 12-19 Years

Less than 1.22 ng/mL Less than 1.16 ng/mL

List of websites:

ATTACHMENT X8

Abnormal Range #3 Environmental Test Results Letter

Normal Ambient/High Cotinine

ABNORMAL RANGE ENVIRONMENTAL TEST RESULTS LETTER

Normal Ambient/High Cotinine

[DATE]

[ID]

[Name]

[Address]

[City, St. Zip]

Dear [NAME]:

Thank you very much for taking part in the Children’s Health after the Storm (CHATS) study. As promised, we are sending you information about the air samples we took in and outside your home.

S incerely,

Diane Wagener, PhD.

Project Director

Children’s Health after the Storms

Reports from in and outdoor air samples (lower is better):

Pollutant	Your Household’s Measurement	Your Community’s Measurement	National Standard
PM10	Xxxxx	xxxxx	xxxx
Nitrogen Dioxide	xxxxx	xxxxx	xxxxx
Tobacco Smoke	xxxxx	Not measured	None

Report of cotinine in the urine (lower is better)

Your Child’s Measurement Measurements in 90% of Children

Ages 3-11 Years Ages 12-19 Years

Less than 1.22 ng/mL Less than 1.16 ng/mL

List of websites:

ATTACHMENT Y

Resource List

Children’s Health after the Storm (CHATS)

Health Care Resources and Information

Metairie, LA

Health Care Facilities

Children's - Klein Lawrence Pediatric Group

Organization: Children's Hospital Medical Practice Corporation

www.chmpc.org

3100 Kingman Street, Ste 110, Metairie, LA 70006

504-887-6355

Children's - Lakeside Children's Clinic
Organization: Children's Hospital Medical Practice Corporation
www.chmpc.org

4740 S I-10 Service Road, Metairie, LA 70001
504-883-3703

Children's - Metairie Pediatrics
Organization: Children's Hospital Medical Practice Corporation
www.chmpc.org

2201 Veteran's Blvd., Ste 300, Metairie, LA 70002
504-833-7374

Children's - Napoleon Pediatrics Metairie
Organization: Children's Hospital Medical Practice Corporation
www.chmpc.org

3040 33rd Street, Metairie, LA 70001
504-219-0880

Daughter’s of Charity Services of New Orleans – Metairie Medical Center

Organization: Daughters of Charity Services of New Orleans
www.dcsno.org

111 N Causeway Blvd, Metairie, LA 70001

504-482-0084

Jefferson Parish Health Unit

111 Causeway Blvd, Metairie, LA 70001

504-838-5100

Jefferson Parish Health Unit

1855 Ames Blvd, Marrero, LA 70072

504-349-8802

Ochsner Health Center – Metairie

2005 Veterans Memorial Blvd., Metairie, LA 70002

504-836-9820

Ochsner Children’s Health Center – Metairie

4901 Veterans Memorial Blvd., Metairie, LA 70006

504-887-1133

VIA LINK Call Center

http://www.vialink.org

New Orleans, LA 70175

504-895-5550

Hospitals

Tulane-Lakeside Hospital

4700 South I 10 Service Road West, Metairie, LA 70001

504-988-5800

East Jefferson General Hospital
4200 Houma Boulevard, Metairie, LA 70006

504-454-4000

Children's - Klein Lawrence Pediatric Group

Organization: Children's Hospital Medical Practice Corporation

3100 Kingman Street, Ste 110, Metairie, LA 70006

504-887-6355

Children’s Hospital – Metairie Center

3040 33rd Street, Metairie, LA 70001

504-832-4033

Children’s Health after the Storm (CHATS)

Health Care Resources and Information

Baton Rouge, LA

Health Care Facilities

Baton Rouge General – Bluebonnet

8585 Picardy Avenue, Baton Rouge, LA 70809

225-763-4000

Baton Rouge General - Mid City
3600 Florida Boulevard, Baton Rouge, LA 70806

225-387-7000

Baton Rouge Primary Care Collaborative

P.O. Box 127, Baton Rouge, LA 70821

Capitol City Family Health Center

3140 Florida Street, Baton Rouge, LA 70806

225-650-2000

LSU Health Care Services Division – Earl K. Long Medical Center

5825 Airline Highway, Baton Rouge, LA 70805

225-358-1000

North Baton Rouge Community Health Center

1414 Fairchild St, Baton Rouge, LA 70807

Ochsner Health Center - Baton Rouge

9001 Summa Avenue, Baton Rouge, LA 70809

225-761-5200

Ochsner Health Center - Baton Rouge

16777 Medical Center Drive, Baton Rouge, LA 70816

225-754-3278

Baton Rouge Crisis Intervention Center

http://www.brcic.org/

Baton Rouge, LA 70808

225-924-1431

Hospitals

Children's Hospital – Outpatient Center of Baton Rouge

720 Connell Park Lane, Baton Rouge, LA 70806

225-216-3047

Our Lady of the Lake

5000 Hennessy Blvd., Baton Rouge, LA 70808

225-765-6565

Children’s Health after the Storm (CHATS)

Health Care Resources and Information

Slidell, LA

Health Care Facilities

Ochsner Health Center – Slidell (Hwy 190 W)

2104 Highway 190 West, Slidell, LA

985-661-3550

Ochsner Health Center – Slidell

2750 E. Gause Blvd., Slidell, LA 70461

985-639-3777

Ochsner Children’s Health Center – Slidell

2370 E. Gause Blvd., Slidell, LA 70461

985-639-3755

Slidell Memorial Hospital Center for Family Health

901 Gause Blvd., Slidell, LA 70458

985-639-8970

Slidell Memorial Hospital Wellness Pavilion

501 Robert Blvd., Slidell, LA 70458

985-847-9355

St. Tammany Community Health Center

1340 14th Street, Slidell, LA

985-607-0400

985-847-0720

St. Tammany Parish Health Unity

Slidell, LA

985-646-6445

VIA LINK Call Center

http://www.vialink.org

New Orleans, LA 70175

504-895-5550

Hospitals

Doctors Hospital of Slidell

989 Robert Boulevard, Slidell, LA 70458

985-690-8200

Slidell Memorial Hospital

1001 Gause Blvd., Slidell, LA 70458

985-643-2200

St. Tammany Parish Hospital

985-898‐4000

Children’s Health after the Storm (CHATS)

Health Care Resources and Information

New Orleans, LA

Health Care Facilities

Common Ground Health Clinic - Algiers

Organization: Common Ground Health Clinic

www.cghc.org

1400 Teche Street, New Orleans, LA 70114
504-361-9800

Children's - Kids First TigerCARE Kenner

Organization: Children's Hospital Medical Practice Corporation

www.chmpc.org

3321 Florida Ave

Kenner, LA 70062

(504) 468-4437

Children's - Kids First MidCity

Organization: Children's Hospital Medical Practice Corporation

www.chmpc.org

4052 Ulloa Street, New Orleans, LA 70119

(504) 488-7505

Children's - Kids First TigerCARE NO East

www.chmpc.org

Organization: Children's Hospital Medical Practice Corporation

14401 Chef Menteur Hwy, New Orleans, LA 70129

(504) 662-0644

Children's - Kids First TigerCARE Canal

Organization: Children's Hospital Medical Practice Corporation

www.chmpc.org

1661 Canal Street , Ste 1200, New Orleans, LA 70112

(504) 299-9980

Children's - Kids First Prytania

Organization: Children's Hospital Medical Practice Corporation

www.chmpc.org

3600 Prytania Street, New Orleans, LA 70115

(504) 899-5437

Children's - Napoleon Pediatrics Uptown

Organization: Children's Hospital Medical Practice Corporation

www.chmpc.org

2820 Napoleon Avenue, Ste. 950, New Orleans, LA 70115

504-897-4242

Daughters of Charity – Carrollton

Organization: Daughters of Charity Services of New Orleans

www.dcsno.org

3201 S. Carrollton Ave, New Orleans, LA 70118

504-207-3060

Daughters of Charity – Health Services

Organization: Daughters of Charity Services of New Orleans

www.dcsno.org

3900 S. Carrollton Ave, New Orleans, LA 70118

504-482-2080

Daughters of Charity - St. Cecilia

Organization: Daughters of Charity Services of New Orleans

www.dcsno.org

4201 N Rampart St, New Orleans, LA 70117

(504) 941-6041

EXCELth Algiers Fischer Clinic

Organization: EXCELth, Inc.

4422 General Meyer Avenue, Suite 100, New Orleans, LA 70114

504-364-4065

EXCELth Family Health Center

Organization: EXCELth, Inc.

9900 Lake Forest Blvd., Suite F, New Orleans, LA 70127

PHONE

EXCELth Ida Hymel/Algiers Community Health Clinic

Organization: EXCELth, Inc.

1111 Newton Street, New Orleans, LA 70114

(504) 658-2550

EXCELth Mobile Medical Unit - Children's Defense Fund

Organization: EXCELth, Inc.

New Orleans, LA 70112

(504) 444-7070

EXCELth Mobile Medical Unit - New Orleans

Organization: EXCELth, Inc.

New Orleans, LA 70112

(504) 444-7071

EXCELth St. Bernard Health Center

Organization: EXCELth, Inc.

3639 St. Bernard Avenue, New Orleans, LA 70122

504-286-2165

Family Health Center – Algiers

Organization: Leading Edge Services International, Inc d/b/a Family Health Center

www.lesint.org

1501 Newton Street C, New Orleans, LA 70114

(504) 361-3777

LSU-HSCD School Based Health Center - At Eleanor McMain

Organization: LSU Health Sciences Center New Orleans (School Based Health Center)

5712 South Claiborne, New Orleans, LA 70125

(504) 359-1120

LSU-HSCD School Based Health Center - At Science and Math

Organization: LSU Health Sciences Center New Orleans (School Based Health Center)

5625 Loyola Avenue, New Orleans, LA 70115

(504) 359-1131

LSU-HCSD Medicine Clinic (Lord & Taylor)

Organization: Medical Center of Louisiana at New Orleans (MCLNO)

1400 Poydras Street, New Orleans, LA 70112

(504) 903-2373

LSU-HCSD School Based Health Center - At O Perry Walker

Organization: Medical Center of Louisiana at New Orleans (MCLNO)

2832 General Meyer Ave, New Orleans, LA 70114

(504) 361-6360

City of NO Health Dept - Edna Pilsbury Health

Organization: City of New Orleans Health Department

www.cityofno.com

2222 Simon Bolivar Avenue 2nd Floor, New Orleans, LA 70112

(504) 658-2825

City of NO Health Dept - Ida Hymel/Algiers Fisher Health

Organization: City of New Orleans Health Department

www.cityofno.com

1111 Newton Street, New Orleans, LA 70114

(504) 658-2550

City of NO Health Dept - New Orleans East

Organization: City of New Orleans Health Department

www.cityofno.com

5640 Read Blvd. #540, New Orleans, LA 70127

(504) 658-2750

Tulane New Orleans Children's Health Project (NOCHP)

Organization: Administrators of Tulane Educational Fund

www.nochp.org

New Orleans, LA 70112

(504) 988-0545

Tulane Drop In Center

Organization: Administrators of Tulane Educational Fund

www.tulane.edu/~dropin

1428 N Rampart St., New Orleans, LA 70116

(504) 948-6701

Tulane Drop-In Clinic at Covenant House

Organization: Administrators of Tulane Educational Fund

www.tulane.edu/~dropin

611 N. Rampart St., New Orleans, LA 70112

(504) 584-1112

Tulane Community Health Mobile Medical Unit

Organization: Administrators of Tulane Educational Fund

www.tuchc.org

New Orleans, LA 70112

(504) 994-0054

Children's - Kids First Louisa

Organization: Children's Hospital Medical Practice Corporation

www.chmpc.org

3512 Louisa Street, New Orleans, LA 70126

(504) 948-2873

Cohen School Based Health Center

Organization: Administrators of Tulane Educational Fund

3520 Dryades Street, New Orleans, LA 70115

(504) 988-4180

Daughter’s of Charity Services of New Orleans – Carrollton Medical Center

3201 S Carrollton Ave, New Orleans, LA 70118

504-207-3060

Daughter’s of Charity Services of New Orleans– St. Cecilia Medical Center

1030 Lessepst St, New Orleans, LA 70117

504-941-6041

VIA LINK Call Center

http://www.vialink.org

New Orleans, LA 70175

504-895-5550

Hospitals

Children’s Hospital – Main Campus

200 Henry Clay Ave, New Orleans, LA 70118

504-899-9511

Children’s Hospital – Calhoun Campus

1040 Calhoun Street, New Orleans, LA 70118

504-896-7200

Interim LSU Public Hospital

2021 Perdido Street, New Orleans, LA 70112-1352

504-903-3000

Children’s Health after the Storm (CHATS)

Health Care Resources and Information

Bay Saint Louis, MS Area

Health Care Facilities

Hancock Medical Center

Organization:

www.hmc.org

149 Drinkwater Blvd., Bay St. Louis, MS 39520

228-467-8600

Coastal Family Health Center: Bay St Louis

Organization:

www.coastalfamilyhealth.org/locations/bay-st-louis/

109 Hospital Dr, Bay St. Louis, MS 39520

228-463-9666

National Hopeline Network

Organization: Emotional Distress Hotline

http://www.hopeline.com/

CONTACT Helpline

Columbus, MS 39703

662-327-2968

Mississippi Deptment of Mental Health - Office of Constituency Services

Jackson, MS 39201

http://www.dmh.state.ms.us

Hospitals

Hancock Medical Services Port

3068 Port and Harbor Drive, Bay St. Louis, MS 39520

228-533-9000

Children’s Health after the Storm (CHATS)

Health Care Resources and Information

Gulfport, MS Area

Health Care Facilities

Coastal Family Health Center

Organization:

www.coastalfamilyhealth.org

15024 Martin Luther King Blvd, Gulfport, MS 39501

228.864.0003

Coastal Family Health Center

Organization:

www.coastalfamilyhealth.org

1408 44th Avenue Gulfport, MS 39501

Primary Care Medical Center of Gulfport

Organization:

http://primarycaremedgulfportmgcms.com/

15444 Dedeaux Road, Suite B, Gulfport, MS 39503

228-832-9038

National Hopeline Network

Organization: Emotional Distress Hotline

http://www.hopeline.com/

CONTACT Helpline

Columbus, MS 39703

662-327-2968

Mississippi Deptment of Mental Health - Office of Constituency Services

Jackson, MS 39201

http://www.dmh.state.ms.us

Hospitals

Garden Park Medical Center GPCH-GP

Organization:

15200 Community Road, Gulfport, MS 39503

228-575-7000

Memorial Hospital

Organization:

4500 Thirteenth Street, Gulfport, MS 39501

228-867-4000

Children’s Health after the Storm (CHATS)

Health Care Resources and Information

Biloxi, MS Area

Health Care Facilities

Coastal Family Health Center

Organization:

www.coastalfamilyhealth.org

1046 Division St, Biloxi, MS 39530

228-374-2494

Biloxi Regional Medical Center

Organization:

www.biloxiregional.net

150 Reynoir Street, Biloxi, Mississippi 39530

228-432-1571

Bethel Free Health Clinic

Organization:

1650 Carrol Drive, Biloxi, Mississippi 39531

228-594-3640

National Hopeline Network

Organization: Emotional Distress Hotline

http://www.hopeline.com/

CONTACT Helpline

Columbus, MS 39703

662-327-2968

Mississippi Deptment of Mental Health - Office of Constituency Services

Jackson, MS 39201

http://www.dmh.state.ms.us

Hospitals

Memorial Hospital

Organization:

4500 Thirteenth Street, Gulfport, MS 39501

228-867-4000

Children’s Health after the Storm (CHATS)

Health Care Resources and Information

Pascagoula, MS Area

Health Care Facilities

Coastal Family Health Center

Organization:

www.coastalfamilyhealth.org

4770 Amoco Drive, Moss Point,MS

228-474-9511

National Hopeline Network

Organization: Emotional Distress Hotline

http://www.hopeline.com/

CONTACT Helpline

Columbus, MS 39703

662-327-2968

Mississippi Department of Mental Health - Office of Constituency Services

Jackson, MS 39201

http://www.dmh.state.ms.us

Hospitals

Singing River Hospital

Organization:

http://srhshealth.com/

2809 Denny Ave, Pascagoula

Notes: Include statement similar to following where appropriate:

Most of the medical centers listed on this site accept private and public health insurance, or payments can be made on an income-based sliding fee scale.

ATTACHMENT Z

Incident Report Form

Children’s Health after the Storms (CHATS)

Incident Report Form

Should you or a study respondent become distressed or find the need to initiate emergency protocols during the course of an interview or health assessment, you must complete this form to document the incident.

If you have questions regarding the form’s completion, please call [Insert name] at 1-xxx-xxx-xxxx. Use the back of this form if more space is needed to record details of events or actions.

This form must be completed immediately following the incident and the information submitted electronically via e-mail to [Laura Strange, your Field Supervisor, QA Team, and Field Director] within one (1) working day of the incident. To protect respondent privacy, please only refer to the respondent by their case ID number and do not use respondent names in e-mail exchanges. This completed hard copy form should be shipped to RTI with the completed case records for this household.

Date of Event: ___ ___ /___ ___/___ ___ ___ ___

Time of Event: ___ ___:___ ____ AM/PM

Case ID Number: ___ ___ ___ ___ ___ ___ ___ ___

Location of Event:

Names and job titles of study staff involved with this event:

Description of event:

Description of actions taken by study staff in response to event:

Description of any deviations from approved data collection procedures:

Signature of staff reporting event:

Date event reported to project staff: ___ ___/___ ___/___ ___ ___ ___

Time event reported to project staff: ____ ____:____ ____ AM/PM

Environmental Assessment (Central Site Equipment Deployment & Retrieval) T-1

File Type	application/vnd.openxmlformats-officedocument.wordprocessingml.document
Author	Kim Adcock
File Modified	0000-00-00
File Created	2021-01-31