Form DOE F 440-1 DOE F 440-1 Chronic Beryllium Disease Prevention Program Informed Co

OMB Control No.
1910-5112

DOE F 440.1
(08-00)
U.S. DEPARTMENT OF ENERGY

10 CFR PART 850 — APPENDIX A
CHRONIC BERYLLIUM DISEASE PREVENTION PROGRAM INFORMED CONSENT FORM
OMB Burden Disclosure Statement
Public reporting burden for this collection of information is estimated to average
hours (or minutes) per response; including the time for reviewing instructions, searching existing data
sources, gathering and maintaining the data needed, and completing and reviewing the collection of information. Send comments regarding this burden estimate or any other aspect of this
collection of information, including suggestions for reducing the burden to the Office of Information, Records, and Resource Management, SO-31, U.S. Department of Energy, Paperwork
Reduction Project (1910-5112), Washington, DC 20585, and to the Office of Management and Budget, Paperwork Reduction Project (1910-5112), Washington, DC 20503.

I,

have carefully read and understand the attached information

about the Be-LPT and other medical tests. I have had the opportunity to ask any questions that I may have had
concerning these tests.
I understand that this program is voluntary and I am free to withdraw at any time from all or any part of the
medical surveillance program. I understand that the tests are confidential, but not anonymous. I understand that
if the results of any test suggest a health problem, the examining physician will discuss the matter with me,
whether or not the result is related to my work with beryllium. I understand that my employer will be notified of my
diagnosis only if I have a beryllium sensitization or chronic beryllium disease. My employer will not receive the
results or diagnosis of any health conditions not related to beryllium exposure.
I understand that, if the results of one or more of these tests indicate that I have a health problem that is related
to beryllium, additional examinations will be recommended. If additional tests indicate I do have a beryllium
sensitization or CBD, the Site Occupational Medical Director may recommend that I be removed from working
with beryllium. If I agree to be removed, I understand that I may be transferred to another job for which I am
qualified (or can be trained for in a short period) and where my beryllium exposures will be as low as possible, but
in no case above the action level. I will maintain my total earnings, seniority, and other benefits for up to two years
if I agree to be permanently removed.
I understand that if I apply for another job or for insurance, I may be requested to release my medical records
to a future employer or an insurance company.
I understand that my employer will maintain all medical information relative to the tests performed on me in
segregated medical files separate from my personnel files, treated as confidential medical records, and used or
disclosed only as provided by the Americans with Disability Act, the Privacy Act of 1974, or as required by a court
order or under other law.
I understand that the results of my medical tests for beryllium will be included in the Beryllium Registry
maintained by DOE, and that a unique identifier will be used to maintain the confidentiality of my medical
information. Personal identifiers will not be included in any reports generated form the DOE Beryllium Registry. I
understand that the results of my tests and examinations may be published in reports or presented at meetings,
but that I will not be identified.

I consent to having the following medical evaluations:
/

/ Physical examination concentrating on my lungs and breathing

/

/

Chest X-ray

/

/

Spirometry (a breathing test)

/

/

Blood test called the beryllium-induced lymphocyte proliferation test or Be-LPT

/

/

Other test(s). Specify:

Signature of Participant

Date

I have explained and discussed any questions that the employee expressed concerning the Be-LPT,
physical examination, and other medical testing as well as the implications of those test.
Name of Examining Physician:
Signature of Examining Physician:
Date: