Child Assent

Add-on Study Child’s ID # ____________

Appendix G - Assent Form

House ID # ____________

CHILD ASSENT FORM

(Ages 7-12 years)

You are being asked to join the add-on study because your home is already being studied for other chemicals.

If you agree to join this study, the following things will happen:

W e will see what kinds of chemicals are in your blood. To find out, we will take 2 teaspoons of blood from your arm. You may feel a little pain. This will only happen one time. If you already gave blood to us, we won’t ask you for another blood sample.

We will ask you to give urine and a sample of feces. We will test the urine and feces for chemicals that are often found in children’s bodies.

Y ou will wear a silicone band around your wrist for 5 days and you will wear a small machine on your waist that records

where you go and how you move around during the daytime.

We will ask you to collect an equal amount of food and drink that you ate or drank over one whole day. We will test these for the same chemicals that we test for in your urine and feces.

When we visit your home we will also do the following:

We will collect dust, water, air and soil from your home. Sometimes we use special machines and sometimes we just use bottles and cloth wipes. We are checking to see if these samples contain chemicals and if they match the chemicals in your body.

Why should you join this study?

Your health may or may not be helped by being in this study. However, we may learn something that will help other children some day.

You do not have to join this study. It is up to you. You can say okay now, and then change your mind later. If you change your mind later, all you have to do is tell us. No one will be upset if you change your mind.

Before you say yes to be in this study, we will answer any questions you have.

If you want to be in this study, please sign your name and fill in the date. You will get a copy of this form to keep for yourself.

______________________________________________ _____________

Sign your name here (Printed name) Date

______________________________________________ _____________

Signature of person obtaining Assent Date

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Readability = 3^rd Grade level