Example Consent Form 30MAR2017

Attachment H

Example Consent Form

Reading level: 6.8

Assessment of Potential Exposure from Private Wells for Drinking Water

Example Consent

The [state health department] is doing this survey to find out about potential exposure to [description of the contaminant] in private well water. They are being assisted by the National Center for Environmental Health (NCEH) of the Centers for Disease Control and Prevention (CDC). CDC is a government agency. NCEH is authorized to collect this information under the Public Health Service Act Section 301 (241).

This interview will take approximately 35 minutes to complete. It should take place in a private setting. We will ask you questions about:

• Your general information

• Your household water source and use

• Your exposure to private well water

• Other things that might affect your exposure to private well water

There are no known risks from taking part in the survey. Some of the questions are personal. There is no direct benefit from being in the survey. However, what you tell us will help us better learn how people may be exposed to drinking water contaminants. [Name of state] will also be able to use what we learn to help your community.

We are asking you to take part in this survey because you get your drinking water from a private well. You can choose if you want to be interviewed. You can stop the interview at any time. You can also refuse to answer any question. If you refuse, it will not affect any government benefits that you receive.

Names of people who take part and other identifying information will not be used in any report. If you would like a copy of the report, one can be sent to you. Everything we learn will be kept private to the fullest extent of the law. Only project team members will be allowed to view your information.

If you have any questions about this investigation of exposure, you can call the XXXXX. XX’s number is (XXX) XXX-XXXX.

By signing below, you agree to take part in the survey. You are also saying we have given you a copy of this consent form. If there is any part of this form that is not clear to you, be sure to ask about it.

_______________________________________ ___________________________

Signature Date

Sometimes public health officials want to follow-up with people who have been exposed to contaminants in drinking water. They may call or send a survey to check in and see how the people are doing. By signing below, you give your permission for us to contact you again.

_______________________________________ ___________________________

Signature Date

(For telephone interviews):

Participant name: ________________________________

Are you willing to take part at this time?

Yes

No Thank the respondent and end the call

I verify that I have explained this survey to you. You have agreed to participate.

Sometimes public health officials want to follow-up with people who have been exposed during chemical releases. They may call or send a survey to check in and see how the people are doing.

Are you willing to be contacted again?

Yes

No Continue with general survey modules

I verify that I have read you information about possible follow-up. You have voluntarily agreed to be contacted again.

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