Consent

Attachment 3: Drinking Water Exposure Investigation Dimock, PA Consent Form

US Department of Health and Human Services (DHHS)

Agency for Toxic Substances and Disease Registry (ATSDR)

Dimock, Susquehanna County Drinking Water Exposure Investigation (EI)

Adult Access/Consent Form

Fleisch-Kincaid 9.0

Who are we and why we are doing this EI?

The Agency for Toxic Substances and Disease Registry (ATSDR) is a federal health agency that works to protect the public from chemicals in the environment. ATSDR is conducting an exposure investigation (EI) in Dimock to evaluate current exposures to contaminants in drinking water and radon in homes in the area. ATSDR is inviting you to have your drinking water tested for contaminants such as salt, metals, natural gas, and other chemicals, such as benzene. ATSDR is also inviting you to have your indoor air tested for radon.

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What will we be testing?

We will test your drinking water. We will collect tap water samples, and, if accessible, we will collect water samples before any treatment systems. We will test supplied bulk water, if you use it. We will test your home for combustible air during the water testing to make sure conditions are safe We will also test indoor air for radon.

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What does this involve?	We would like you to volunteer to be part of this investigation. We need your written permission to test your drinking water and indoor air and ask you some questions. This will take about an hour of your time. Drinking Water Testing: We will collect samples of your drinking water from your kitchen tap and put it into specially prepared bottles. This will take slightly over an hour. If you have a water treatment system, we will also take a sample of the water before it goes through the system. Water sample containers will be sent to a laboratory for chemical tests. These tests determine the concentrations of salts, metals and other chemicals, such as benzene. During the water testing, we will monitor indoor air to make sure conditions are safe for the sampling team and the homeowner.
	Bulk Water Testing: If you are supplied bulk water for drinking and household use, we will collect a sample of the water and send it to the laboratory for the same analyses as your drinking water. Indoor Air Radon Testing: We will place radon test kits in your home to test indoor air for radon gas. They will be placed in your kitchen and basement, if you have one. It will take about half an hour to set up the monitors and half an hour to collect the monitors when they have completed their testing cycle (approximately 3 days). Answering Questions: We will ask you questions about your water, well history, any water softening or treatment system you use, if you know of any natural gas wells nearby, and whether you have had any radon testing in the past. The questions will take about 20 minutes to complete. Test Results: ATSDR will mail you the test results and tell you what the results mean to you and your family. We will be available to answer any questions you have about the results.

When will I get my results?

You will get your results by mail about 12 weeks after testing. ATSDR will be available by phone to explain your results.

What are the benefits from being in this EI?

You will find out if your drinking water, groundwater, and supplied bulk water contains chemicals that might be harmful to you and your family. If we find chemicals that may be of concern for your health, we will recommend things you can do to reduce the risk of coming in contact with the chemicals. You will find out if your indoor air contains radon at levels of health concern. If your radon levels are high, you may consider installation of a radon treatment system.

What are the risks of this EI?	There are no risks to you or your family from having your water and indoor air tested as part of this EI. You might be inconvenienced. It will take about 20 minutes for us to ask you questions during the pre-visit and about an hour to collect your well water and stage radon test kits in your home on the test day. We may need to run water from the well for a period of time which might lower the volume of water in your well for a brief recharge period and may leave a wet area in your yard due to purging of the well volume. If you have a treatment system, we may need to get the water sample directly from the well. We might need to turn off your well for a short period of time while we take samples.
What if I have questions?	If you have any questions about this testing, you can ask us now. If you have questions later, you can call Robert Helverson at 215-814-3139. Or call the ATSDR toll free number at 1-888-320-5291.
What about privacy?		We will protect your privacy as much as the law allows. Your water sample will be identified with an identification (ID) number and not your name, We will not use your name in any report we write. We will keep a record of your name, address and ID number so that we can send you the test results. ATSDR will keep your personal information in a password protected computer. Information given to the Commonwealth (i.e., Pennsylvania Departments of Environmental Protection and Health, or PADEP and PADOH) is subject to Pennsylvania’s “sunshine laws,” which are different than federal rules for public disclosure of information. If you give us permission, we will share information about your well water with the PADEP, PADOH and federal environmental and public health agencies as needed so they can make informed public health decisions. By signing this consent form, you are agreeing to let us share your results with other agencies if needed. If you initial “yes” to the statement above your signature you will also be agreeing to allow us to share your personal identifying information (name, address, contact information) with other environmental and public health agencies, if needed, in order for them to take additional steps as necessary to protect public health and the environment. After the final report is written, all personal information will be destroyed by ATSDR.
Voluntary Consent		I am at least 18 years of age. I am the property owner (if you are renting, both the resident and the property owner must consent to the testing below). I agree to have my drinking water, groundwater and bulk water (as appropriate) tested by ATSDR. I agree to have my indoor air tested for radon. I agree to answer the questions that ATSDR will ask me about my private well and water use. I agree to have my drinking water test results shared with other Pennsylvania and federal environmental and public health agencies, if needed. My personal information will not be shared with other agencies without my consent. I have been given the chance to ask questions. I know that having my well tested and indoor air monitored is my choice and voluntary. I will be given a copy of this form to keep. I know that even though I have agreed to this testing and answering question that I can change my mind at any time without penalty.

Signature of Resident

Do you consent to participate in this Exposure Investigation and allow ATSDR to test your drinking water, groundwater and indoor air? YES__________NO_________ May we share your personal information with other federal or Pennsylvania health and environmental agencies, if needed, in order to make informed public health decisions (You may check “NO” and still participate in this investigation)? If this information is shared with other Pennsylvania state and federal environmental and public health agencies, they will also protect your privacy to the extent that the law allows (check one). YES_________, NO________ I have read this form or it has been read to me. I give my permission to have my water and indoor air tested and to answer the questions ATSDR asks me. _____________________________ _______________ Signature of Person Given Consent Date ________________________________________ Printed Name of Person Given Consent Age _________ Street Address (If this address has another defining number or letter, please provide that now): ______________________________ ______________________________ ______________________________ Mailing Address (If different from Street Address): ______________________________ ______________________________ ______________________________ Telephone__________________ Cell phone _________________ Email Address: ________________________________________

Signature of Property Owner

Do you consent to participate in this Exposure Investigation and allow ATSDR to test the drinking water, groundwater and indoor air at your property? YES__________NO_________ May we share your personal information with other federal or Pennsylvania health and environmental agencies, if needed, in order to make informed public health decisions (You may check “NO” and still participate in this investigation)? If this information is shared with other Pennsylvania state and federal environmental and public health agencies, they will also protect your privacy to the extent that the law allows (check one). YES_________, NO________ I have read this form or it has been read to me. I give my permission to have my water and indoor air tested and to answer the questions ATSDR asks me. _____________________________ _______________ Signature of Property Owner Date ________________________________________ Printed Name of Property Owner Age _________ Street Address of property being tested: ______________________________ ______________________________ ______________________________ Mailing Address of property owner: ______________________________ ______________________________ ______________________________ Telephone__________________ Cell phone _________________ Email Address: ________________________________________

Signature of Consent Form Administrator

Certification of Consent Form Administrator: I have read the consent form to the person name above. They have had the opportunity to ask questions about the EI and had the questions answered. ___________________________________ ___________ Signature of person administering consent Date _________________________________________ Printed Name of person administering consent