Children's Assent Form for Blood and Urine PFC Testing and Questionnaire (12 -

Attachment 3C: Children’s Assent Form for Blood and Urine PFC Testing and Questionnaire (12 - < 18 years of age)

(ATSDR OMB Control No. 0923-0048 / Expiration Date: 5/31/2016)

U.S. Department of Health and Human Services

Agency for Toxic Substances and Disease Registry

PFC Exposure Investigation, blood and urine sampling

Assent Form for Children (12 - < 18 Years)

Flesch-Kincaid Reading Level (without agency or chemical names): 6.1

Who are we and why are we doing this blood testing?

We are from the Agency for Toxic Substances and Disease Registry (ATSDR), a federal public health agency. We are inviting you to have your blood and urine tested for chemicals called Perfluoroalkyl Compounds (PFC). You will find out how much of the PFC chemicals are in your blood and how quickly they are removed from your body. You will also find out how exposure in your community has changed since 2010.

These chemicals have been found in your community in soil fields treated with sludge from the local wastewater treatment plant. People that work or live near these fields may come into contact with these chemicals. These chemicals have also been found in some private wells and in one water system. Scientists do not clearly understand how these chemicals can affect a person’s health.

What is involved in this blood testing?

A 5 milliliter (mL) sample of blood (about 1 teaspoon) will be taken from a vein in your arm. If you are anemic (low blood cells) or have a bleeding problem, we will not take your blood.

In the urine test, you will be given a container to collect all of the urine from the first time you urinate the day of your sample collection. You will also be asked to write down the time of the last time you urinate prior to collecting your urine sample.

You will be asked to have your height, weight, and body fat percentage measured using a measuring stick, scale, and digital body fat analyzer and recorded. This information will help ATSDR to better understand your exposures.

Some of the data from this investigation will be kept for potential study in the future. If you give permission, your blood sample will be saved for future tests. None of the data that is kept will be linked to your name or address.

We will not use your name or address in any of our reports.

What are the benefits from being involved in this testing effort?

You will find out the amount of PFC chemicals in your blood and you may find out how quickly your kidneys remove some PFC chemicals from your body. You will also learn if exposures to these chemicals have changed in your community since 2010. Your test results will help advance research about PFCs. We will give you written information about PFC chemicals.

We will not be able to tell you if the PFC levels in your blood will make you sick. We will not be able to tell you specifically where the PFCs came from or how they got into your body.

This testing is free for you.

What are the risks of being tested?

The needle might hurt and their might be a little bruising where the blood sample is collected.

Place ID # label here

For office use only

Assent

Your parents/guardian said it is all right for you to have this test. You don’t have to get tested if you don’t want to. Even if you say we can test you, you can change your mind at any time.

What if I have questions?

If you have questions, you can ask us now. You can talk with your parents if you want. If you have questions later, you may ask your parent. Your parent or you can call or email us for answers.

SIGNATURE

I have talked with someone about this test. I asked questions, if I wanted to. I agree to be part of this testing.

__________________________________________ ______________________

Signature of Minor Date

__________________________________________

Printed Name of Minor

May we share these test results with other Federal and State health and environmental agencies? Your identifying information will be protected should you choose to share your results with other federal or state agencies.

YES or NO (Circle One)

Address: ____________________________________________

____________________________________________

Phone - Home #: __________________

Phone - Cell #: ___________________