Consent Form Methyl Bromide - FY2015 Q3

Assessment of Chemical Exposures (ACE) Investigations

General Survey Consent/Adolescent (14–17 yrs.) Assent/Parent Permission

The U.S. Virgin Islands Department of Health is doing this survey to find out about the health of people who may have been exposed to methyl bromide. The Department of Health is being assisted by the Agency for Toxic Substances and Disease Registry (ATSDR). ATSDR is a federal agency.

This interview will take approximately 25 minutes to complete. It should take place in a private setting. We will ask you questions about:

• how long you were in the area where methyl bromide had been used to fumigate,

• your health before and after this time period,

• and work history (if relevant).

There are no known risks from taking part in the survey. Some of the questions are personal and ask about sickness and medicines. There is no direct benefit from being in the survey. However, what you tell us will help us better learn this chemical release affected people's health.

We are asking you to take part in this survey because you were in the area where methyl bromide had been used.

All information will be kept private. The names of people taking this survey 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 this information.

You may stop the interview at any time and may choose not to answer any question. If you don’t want to be interviewed, that’s okay. Participation in this survey is not tied to any benefits you might receive.

If you have any questions about this investigation, you can call the coordinator of the ATSDR Assessment of Chemical Exposures program, Mary Anne Duncan at (404) 567-3256.

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

If participant is a minor aged 1417:

As the parent/legal guardian for the above signed, I give my permission for him/her to take part in this interview.

_______________________________________ ___________________________

Parent/Guardian Signature Date

(For telephone interviews):

Participant name: ________________________________

If participant is a minor aged 1417:

Name of parent/guardian: ________________________________

Are you willing to take part at this time?

Yes

No Thank the respondent and end the call

If participant is a minor: Has your parent or legal guardian agreed for you to participate?

Yes

No Thank the respondent and end the call

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

If participant is a minor: Your parent or legal guardian has also agreed for you to participate in this interview.