Parental Permission Form for Storage of Blood Sample for Use in Future Research for Children (12 -

Attachment 3F: Parental Permission Form for Storage of Blood Sample for Use in Future Research for Children (12 - < 18 Years) Participating in Investigation

(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

Parental Permission form for Storage of Child’s Blood Sample for Use in Future Research

Flesch-Kincaid Reading Level (without agency or chemical names): 7.2

What is this about?

Research to better understand the health effects associated with PFC exposure is ongoing, but scientists are not currently certain of how PFC levels in the blood can affect a person’s health. More research is needed to clarify the risks posed by PFC exposure. It is possible that new tests will be developed in the future that will increase our understanding of how PFCs impact human health. We would like to keep your child’s blood sample for five years so that scientists can test for more things if new tests are developed. To do this, we need your permission.

Your child’s name will not be connected with any of the test results.

What are the risks?

Some people may feel uncomfortable about having their blood tested for other things.

Are there benefits for me?

There is not direct benefit to your child if you let us keep their blood sample for future tests. But, helping carry out this research may increase our understanding of how PFCs impact human health.

Do I have to give permission?

If you do not want your child’s blood to be used for other tests, it is okay. If you are okay with further testing, you must sign this form and your child must sign the assent form.

What about confidentiality?

If you allow us to save and use your child’s blood, we will break the link between your child’s name and their 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 your child.

Is there compensation?

Your child 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. If you have questions later, or if you change your mind about having your child’s sample stored, you can call Rachel Worley or Bruce Tierney, MD of ATSDR toll-free at 1-855-288-0242, or email them at [email protected] or [email protected]. 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 child’s blood sample to be saved and used for other tests. I know allowing further testing is my and my child’s choice. I know I can change my mind at any time before the link between my child’s name and their specimen is broken. I will be given copy of this permission form to keep.

Place ID # label here

For office use only

SIGNATURE

I give permission for my child’s blood samples to be saved and used for other tests.

________________________________ ___________/__________

Parent/Guardian Signature Date Time

________________________________

Parent/Guardian Printed Name

________________________________

Child’s Printed Name