Att T - Consent

DEPARTMENT OF HEALTH & HUMAN SERVICES

Public Health Service

Agency for Toxic Substances and Disease Registry

_{Atlanta, GA 30333}

INFORMED CONSENT FORM

ATSDR Health Survey of Marine Corps

Personnel and Civilians

Introduction and Purpose

The Agency for Toxic Substances and Disease Registry (ATSDR) is doing a health survey of persons who lived or worked at Camp Lejeune or Camp Pendleton in 1985 or before. The ATSDR Health Survey of Marine Corps Personnel and Civilians is funded by the U.S. Navy and the Marine Corps. ATSDR is doing this survey to learn more about the health effects of workplace and environmental exposures. The survey asks questions about when and where you lived or worked at Camp Lejeune or Camp Pendleton. It also asks about your work history and your health.

If you agree to take part, please read and sign this consent form and complete the following survey. The survey should take about 45 minutes to complete.

Risks and Benefits

Data are collected through a mail questionnaire with minimal risk to participants. Some of the questions are personal, like questions about your health. Answering the survey is voluntary. If you choose not to take part, there will be no penalty. You will not lose any benefits if you decide not to participate. There are no direct benefits from taking part in this survey.

Confidentiality

All answers you give will be kept private to the extent permitted by law. We do not plan to share your information with anyone other than ATSDR staff and its contractors. Data that identify you or where you live will not be included in any report. All information from the surveys will be kept in a locked file. Data will be stored separately from any personal identifiers.

If you have any questions about this survey, please contact the Centers for Disease Control and Prevention (CDC) Information Line at 1-800-232-4636. For questions about your rights as a survey participant, please contact CDC’s Human Research Protection Office at 1-800-584-8814.  Please leave a brief message with your name and phone number, and mention that you are calling about CDC protocol #5536.   Someone will return your call as soon as possible.

PLEASE SIGN THE CONSENT FORM

ON THE FOLLOWING PAGE BEFORE

BEGINNING THE SURVEY

PLEASE READ AND SIGN BELOW

I have read or have had read to me the description of the ATSDR Health Survey of Marine Corps Personnel and Civilians. I have been informed of the risks and benefits of the survey.

My rights as a research subject have been explained to me. The purpose of the survey and how it is being done have been explained to me. I understand that I have the right to refuse to answer any question or refuse to complete the survey. I voluntarily agree to take part in this survey.

Your name (please print)

Your signature

Date

I agree to potentially being re-contacted by ATSDR regarding participation in future studies about Camp Lejeune. I understand that agreeing to be contacted in the future is voluntary.

_{Yes, I agree}

_{No, I do not agree}

Your name (please print)

Your signature

Date