Children's Assent Form for Storage of Blood Sample for Use in Future Research (12 - < 18 years of age)

Attachment 3D: Children’s Assent Form for Storage of Blood Sample for Use in Future Research (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

Child Assent (12 - <18 years) for Storage of Blood Sample for Use in Future Research

Flesch-Kincaid Reading Level (without agency or chemical names): 5.2

What is this about?

Scientists are not currently sure how PFC levels in the blood can affect a person’s health. They need to do more research is needed to figure out what happens when people are exposed to PFCs. It is possible that scientists will discover new tests that can be used to learn how PFCs impact human health. We would like to keep your blood sample for five years so that scientists can test for more things if new tests are developed.

We can only do this if you let us. You do not have to let us. Please take your time to decide. Talk about it with your parents or guardian if you want.

Will any of this hurt me?

No but you might think it is weird have us save and test your blood for other things.

How can this help me?

We don’t think this project will help you at all. It will help scientist do a better job figuring out what happens when people are exposed to PFCs.

Do I have to give permission?

You do not have to do this. If you say no, it is OK.

What about confidentiality?

If you allow us to save and use your blood, we will break the link between your name and your sample before any more tests are done. We don’t believe it will be possible to connect the results of any new tests back to you.

Is there compensation?

You will not be paid.

Who do I contact if I have questions?

If you have any questions about this testing, you can ask us now. You can talk with your parents if you want to. If you have questions later, or if you change your mind about having your sample stored, you can call Rachel Worley or Bruce Tierney, MD of ATSDR toll-free at 1-855-288-0242, or email them at RWorley@cdc.gov or BTierney@cdc.gov. If you have questions about your study rights you may contact the Centers for Disease Control and Prevention’s Institutional Review Board at 1-800-584-8814.

VOLUNTARY CONSENT

I agree to allow my blood sample to be saved and used for other tests. I know allowing further testing is my choice. I know I can change my mind at any time before the link between my name and my specimen is broken. I will be given copy of this permission form to keep.

Place ID # label here

For office use only

SIGNATURE

I have talked with someone about this. I asked questions if I wanted to. I give permission for my blood samples to be saved and used for other tests.

________________________________ ___________/__________

Signature of minor Date Time

________________________________

Printed Name of minor