3 Missing Buccal Cell Consent Forms Call Script

OMB NO.: 0925-0406

EXPIRATION DATE: xx/xx/2016

Attachment 9.4: Phase IV Buccal

Agricultural Health Study Missing Buccal Cell Consent Forms Script

Collection of this information is authorized by The Public Health Service Act (42 USC 285l). Rights of study participants are protected by The Privacy Act of 1974. Participation is voluntary, and there are no penalties for not participating or withdrawing from the study at any time. Refusal to participate will not affect your benefits in any way. The information collected in this study will be kept private to the extent provided by law. Names and other identifiers will not appear in any report of the study. Information provided will be combined for all study participants and reported as summaries. You are being contacted by mail to complete this health follow-up survey because as a member of the Agricultural Health Study your continued involvement can help us learn more about how agricultural and environmental factors may affect the health of farmers and their families.

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.

This is _______ with the Agricultural Health Study. 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.