Att3A_ASARCO EI_Parental Permission_ChildUnder6_Oct23_2014

Attachment 3A

Parental Permission Form for Blood Lead Testing and Questionnaire

Children aged 9 to <72 Months

ATSDR Exposure Investigation (EI)

ASARCO Smelter - Hayden/Winkelman, AZ

Who are we?

• We are from a federal public health agency, the Agency for Toxic Substances and Disease Registry (ATSDR), and the Arizona Department of Health Services (ADHS).

Why we are doing this Exposure Investigation?

• We are doing this Exposure Investigation to find out if children living in Hayden or Winkelman, AZ, have high levels of lead in their blood.

What do we want you to do?

• Your child is invited to have his/her blood tested for lead.

• There is NO COST to you for the testing of your child.

• The blood collection will take place at XXX.

What is included in my child’s participation?

There are two parts to your child’s participation.

1. Blood Collection and Testing for Lead

• We will collect less than 1 teaspoon (3 milliliters) of blood from a vein of your child’s arm.

• This will take 5 minutes or less.

• We will send your child’s blood to a lab to test it for lead.

2. Answer Some Questions:

• We will ask you some questions about your child.

• This should take about 20 minutes.

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

• The lab will throw out any leftover blood. It will not be used or tested for anything else.

When will you get the test results?

• You will get your child’s test results by mail about 12 weeks after testing.

What are the benefits from being in this Exposure Investigation?

• You will know if your child has a high level of lead in blood.

• If your child has a high blood lead level, ATSDR and ADHS will provide you with information that will help you reduce your child’s contact with lead.

What are the Risks of this EI?

• Your child might cry because the needle hurts

• Your child’s arm may become bruised where the blood is taken from.

• Your child may feel dizzy or lightheaded

How will we protect your privacy?

• We will protect your and your child’s privacy as much as the law allows.

  • Arizona law requires that we report blood lead levels to ADHS.

  • Arizona law requires that information given to the state may be made public if someone asks them for the information.

• We will give your child an identification (ID) number.

  • Your child’s ID number, not his/her name, will go on the tube of blood.

  • We will keep a record, under lock-and-key, of your child’s name, address and ID number. We will use this information to link your child’s results with his/her name so we can send you your child’s test results.

• We will not use your or your child’s name in any report we write. Only group information that does not include individual names will be reported.

When can you ask questions about the testing?

• If you have any questions about this testing, you can ask us now.

• If you have questions later, you can call:

  • Dr. Bruce Tierney at 770-488-0771 

  • The ATSDR toll free number 1-888-320-5291

Parental/Guardian Voluntary Permission

• I agree to have my child tested.

• I was given the chance to ask questions on behalf of my child. I feel my questions have been answered.

• I know that having these tests done is my choice.

• I know that even though we agreed to this testing, I and my child may leave at any time without penalty.

Signature

I give permission for my child to be tested.

______________________________________ ______ ___________

Printed name of child Age Sex of child

___________________________________ __________________

Signature of parent/guardian Date

___________________________________

Printed name of parent/guardian

Address of Child _____________________________ Telephone __________________

______________________________

______________________________

May we share the test result with other federal, state, and local health and environmental agencies? YES / NO (please circle one)

Lab ID Number____________________

Certification of Permission Form Administrator:

I read the permission 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 permission