Assent Form for Children and Youth 7 to less than 18 Years of Age

Attachment 3B: Assent Form for Children and Youth 7 to less than 18 Years of Age

Flesch-Kincaid Reading level – 4.9

Follow Up Biologic Testing for Exposure to Arsenic

ASARCO Hayden Smelter Site, Hayden & Winkelman, Arizona Exposure Investigation

Assent Form for Urine Arsenic Testing and Questionnaire

Children and Youth 7 years to less than 18 years of age

Who are we?

• We are from a federal public health agency, the Agency for Toxic Substances and Disease Registry (ATSDR), and the Arizona Department of Health Services (ADHS).

Why we are doing this Exposure Investigation?

• We are doing this Exposure Investigation to find out if children and youth living in Hayden or Winkelman, AZ have high levels of arsenic in urine.

What are we asking you to do?

• You are invited to have your urine tested for arsenic.

• There is NO COST to you or your parents for the testing.

Place for Blood and Urine Collection

• The urine collection will take place in your home or at the XXX.

What is part of my participation?

There are two parts to your participation.

1. Urine Collection and Testing for Arsenic

• You can collect the urine at your home or at the designated urine collection facility.

• You will collect your urine in a plastic cup we give you. Your parents can help you do this, if you need help.

• It takes 5 minutes to collect your urine.

• We will send your urine to a lab to test it for arsenic.

2. Answer Some Questions

• During the appointment we will ask you some questions

• This will take about 20 minutes.

• Your parents can help you with the questions, if you want.

What will happen to any leftover blood and urine?

• The lab will throw out any leftover urine. It will not be tested or used for anything else.

When will you get the test results?

• You will get your test results by mail about 12 weeks after testing.

What are the benefits from being in this Exposure Investigation?

• Your parents and you will know if you have a high level of arsenic in your urine.

• If you a high urine arsenic level, ATSDR and ADHS will provide you and your parents with information that can help you reduce your contact with arsenic.

What are the Risks of this EI?

• There is no risk from collecting urine.

How will we protect your privacy?

• We will protect your privacy as much as the law allows.

  • Arizona law requires that information given to the state may be made public if someone asks them for the information.

• We will give you an identification (ID) number.

  • We will use your ID number on the urine cup.

  • We will keep a record, under lock-and-key, of your name, address and ID number so we can send the test results to your parents.

• We will not use your name in any report we write. Only group information that does not include your name will be reported.

When can you ask questions about the testing?

• If you have any questions about this testing, you can ask us now.

• If you have questions later, you can call:

  • Dr. Bruce Tierney at 770-488-0771

  • The ATSDR toll free number 1-888-320-5291

Child Assent

• Your parent/guardian said it is all right for you to have this urine test.

• You don’t have to have this test if you don’t want to.

Voluntary Assent

• I agree to be tested.

• I was given the chance to ask questions and feel my questions were answered.

• I know that having these tests done is my choice.

• I know that even though I have agreed to this testing, I may leave at any time without penalty.

Signature

I agree to be tested.

_________________________________________ ___________ ______________

Printed name of child Age of child Sex of child

______________________________________________ __________________

Signature or written name of child in child’s handwriting Date

__________________________

Printed name of parent/guardian

Address of child ______________________________ Telephone __________________

______________________________

______________________________

May we share the test results with other federal, state, and local health and environmental agencies? YES / NO (please circle one)

Lab ID Number____________________

Certification of Assent Form Administrator:

I read the assent form to the person named above. He/she had the opportunity to ask questions about the Exposure Investigation and had the questions answered.

_______________________________________

Signature of person administering the assent