0920-1173 Consent Form

Attachment D

Consent Form

NOTE TO REVIEWERS: We plan to include private well location information in the publically available database managed by USGS. Handling private well data in this manner is common practice in USGS, which has policies in place to address its use. In addition, about half of U.S. states already require homeowners to provide any information they have about the quality of their private well water quality to prospective buyers; thus alleviating concerns about negative impacts on private property values. There is a paper in press about this: Kristina Bowen, Tara Krishna, Lorraine Backer, Kate Hodgins, Lance A. Waller, and Matthew O. Gribble. State-Level Policies Concerning Private Wells in the United States.

Exposure to Arsenic and Uranium in Private Well Water

Consent Form

Introduction

<State>, the Centers for Disease Control and Prevention (CDC), and the U.S. Geological Survey are doing a water quality investigation in <state>. This investigation will assess exposure to arsenic and uranium in drinking water from private wells in your state. The data will help state health departments know whether there is a need for public health activities to reduce exposures. We are being assisted by your <state health/environmental agency>. The Public Health Service Act (Section 301, 42 U.S.C. § 241) lets CDC collect this kind of information.

Investigation summary

We would like you to volunteer to be part of this project

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

For this investigation, we will ask you do three things for us

1. Provide a urine specimen that we will test for arsenic and uranium.

2. Allow us to take two water samples (one from your well and one from your tap) that we will test for arsenic and uranium.

3. Complete a survey. In the survey, we will ask you questions about your general information, your household water source and use, and other things that might affect your exposure to chemicals that may be in your well water.

It will take about 30 minutes for us to collect the water samples and about 10 minutes for you to provide the urine specimen. It will take about 30 minutes to complete the survey.

We will not ask you any questions about your health or medical history.

Privacy

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

• We will give you an identification (ID) number. Your ID number, not your name, will go on the water samples, your urine specimen, and your survey.

• We will keep a record of your name, address, and ID number so that we can send you the water and urine test results. USGS will keep your personal information in a password-protected computer. Your signed consent form will be kept in a locked file cabinet.

• Names and contact information of people who take part will not be used in any report. Everything we learn will be kept private to the fullest extent of the law.

• Your name and address will be deleted from our files after our report is finalized.

• If you give us permission, we will share information about your well location (GPS coordinates) and water test results in the publically available database that USGS manages.

Can we include your well location information in the publically available database?

Yes ____ No_____

Risks from being in the investigation

• There are no risks to you or your family from having your well tested as part of this investigation.

• There may be a risk from having your well location and testing results in a publically available database.

• You might be inconvenienced because it will take about 60 minutes for us to collect your well water and tap water, collect your urine sample, and ask you questions. We may need to run water from the well for a brief period of time which might leave a large wet area in your yard.

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

• If you have any questions about this water quality investigation, you can call the <project leader>. XX’s number is (XXX) XXX-XXXX.

Benefits from being in the investigation

• We will provide you with the results from your urine and water tests.

• You will find out if your water contains arsenic or uranium in amounts that might be harmful to you or your family.

• If we find arsenic or uranium in amounts that may be harmful, you can contact your state Department of Health learn about things you can do to reduce the risk of coming in contact with the chemicals.

Would you like a copy of the report from this investigation?

If you would like a copy of the report, we can send you one. Please provide your email so we can send you a copy of the final published report.

__________________________________________

Email address

By signing below, you agree to take part in the investigation. 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