MERS-CoV Serology Assent

Form Approved

OMB No. 0920-1011

Exp. Date 03/31/2017

Serology Consent/Assent Script for Asymptomatic Passengers and Crew

As part of our contact investigation we are asking passengers and crew to get a blood test for MERS.

The test will help tell us if some people exposed to MERS can be infected without showing symptoms. This would involve drawing a small amount of blood (for adults 1 teaspoon, for infants or young children half a teaspoon or less). There will be no cost to you for doing this testing. Drawing blood can cause some pain, bruising or a small amount of bleeding at the site of the blood draw, and can make some people feel lightheaded.

We will give you the results of the test, but they will not be available in time to make any decisions about your health care. Leftover blood will be stored at CDC and might be used for MERS testing in the future, such as developing new tests for MERS infection. If you agree to do the blood test, we will follow up with you at a later date (in approximately 2-3 weeks) with more details about how and where to have your blood drawn.

Do you have any questions?

Would you be willing to let us do a MERS blood test? Yes No

If NO: thank the person for their time.

Public reporting burden of this collection of information is estimated to average 5 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 CDC/ATSDR Reports Clearance Officer; 1600 Clifton Road NE, MS D-74 Atlanta, Georgia 30333; ATTN: PRA (0920-1011)