Letter to Provider

Pease Study

Letter to Provider – Record Abstraction

Flesch-Kincaid Readability Score – 12.5

Attachment 19 - Letter to Provider for Record Abstraction

[ON AGENCY LETTERHEAD]

[DATE]

[NAME OF PROVIDER]

[ADDRESS]

[CITY, STATE ZIP CODE]

Subject: Medical verification and records review for Pease Study

Dear [NAME OF PROVIDER]:

The Agency for Toxic Substances and Disease Registry (ATSDR) is conducting a research study of the health effects from exposure to per- and polyfluoroalkyl substances (PFAS) found in Pease, NH, drinking water. We are working with the assistance of your local health department, the New Hampshire Department of Health and Human Services (NH DHHS), and [name of all other partners]. ATSDR is conducting this research study with oversight from the CDC/ATSDR Institutional Review Board (IRB) under CDC Protocol No. xxxxxxx.

Under Section 8006 of the 2018 Consolidated Appropriations Act, Congress authorized ATSDR to study the impact that exposure to PFAS in drinking water might have on the health of Pease citizens. This study will see if there is an increase of symptoms or illness related to these chemicals.

ATSDR will include about 1,000 adults and 350 children served by the Pease Tradeport Water System during the time of PFAS contamination. We have included a comparison group of about 100 adults and 175 children from Portsmouth, NH. ATSDR selected Portsmouth because it is very similar to Pease for social and economic factors; it has not experienced PFAS contamination in its water supply.

[ADULT PARTICIPANT’S NAME or PARENT OR GUARDIAN’S NAME] has given the study investigators authorization to conduct a medical records review. ATSDR is interested in more information about [ADULT PARTICIPANT’S NAME/CHILD PARTICIPANT’S NAME]’s self-reported health conditions that may be related to chemical exposure. We have included an abstraction form for your office to fill out and return to us in the enclosed return envelope.

If we need additional information, the ATSDR study team may wish to review the medical records in your office. We would appreciate your assistance if this is necessary.

ATSDR is an agency of the U.S. Department of Health and Human Services. ATSDR is performing this activity as a public health authority as defined by the Health Insurance Portability and Accountability Act (HIPAA) [45 CFR §164.501]. The requested information represents the minimum necessary to carry out the public health purposes of this study as described in 45 CFR §164.514(d) of the Privacy Rule. The research is also covered by a Certificate of Confidentiality under Section 301(d) of the Public Health Service (PHS) Act, as amended by Section 2012 of the 21st Century Cures Act, P.L. 114-255 (42 U.S.C. 241(d))

For questions about this research study, please call the ATSDR study lead, Dr. Marian Pavuk, at [study telephone number]. Please leave a message with your name and a telephone number or address.

Thank you for your assistance.

Marian Pavuk, MD, PhD Frank Bove, DSc

Co-Principal Investigators

Pease Study