Parental Permission

Appendix B4: Parental Permission Form

PFAS Environmental Sampling at Select Exposure Assessment Sites

Parental Permission Form (<18 years of age)

Flesch-Kincaid Reading Level: 9.9

Thank you for participating in the environmental sampling EI.

This Parental Permission Form should be completed by one adult in the household for all children in the household younger than 18 years that provided a blood sample during the Exposure Assessment. The child (with assistance from parent as needed) will agree to complete:

• The Child Personal Exposure Questionnaire

ATSDR will pick up this form from you when we come to your home for the environmental sampling.

Your child/ward is invited to take part in an environmental sampling Exposure Investigation (EI) that will measure per- and polyfluoroalkyl substances (PFAS) at your home. We are trying to find out the levels of PFAS in the homes of people who participated in the PFAS Exposure Assessment (EA) in (Insert name of city/town/place here).

We want to give you some information about it so you can decide whether you want your child/ward to participate.

The main goal for this investigation is to look at non-drinking water sources of PFAS by sampling things like inside air, dust, and soil at your home. We will ask you to fill out a parental permission form for your child/ward so your child can complete a personal exposure questionnaire. If you child/ward is younger than 12 years old, you can complete the questionnaire for them. Older children will need to be present and complete an Assent form where they agree to participate.

We hope you will agree to let your child/ward be part of this exposure assessment. If you have any questions about this form at any time while filling it out, please don’t hesitate to ask. Thank you for considering allowing your child/ward to be in this assessment.

This form contains information about the sampling and what will happen if you decide to allow your child/ward to participate. If you agree to allow your child/ward take part in this PFAS sampling, please sign at the end of the form.

PFAS Environmental Sampling and Questionnaire Completion

CDC/ATSDR will ask you to agree to the following to be included in the Exposure Investigation:

1. Sign this parental permission form allowing CDC/ATSDR to use the results of the PFAS blood sampling and the questionnaire from the EA for your child/ward. If CDC/ATSDR sampled tap water and dust samples in your home as part of the EA, we would also like to use those PFAS results.

2. Allow your child/ward to complete the personal exposure questionnaire. You may assist your child/ward or complete it for them if they are younger than 12 years old. If they are between 12 and 17 years old, they will need to complete an Assent form and must be present to complete the questionnaire.

It will take about 15 minutes to complete the personal exposure questionnaire.

There will be no cost to you for the sample collection or the laboratory analysis. No blood or urine sampling will be completed as part of this EI.

The Benefits of Taking Part in Our Exposure Assessment

Your child/ward’s participation in this investigation will help us better understand exposure to PFAS that is not in drinking water. You will find out the levels of PFAS in your home.

The Risks of Taking Part in Our Exposure Assessment

Your or your child/ward may be inconvenienced by completing the personal exposure questionnaire. It will take about 15 minutes to complete.

Additional Information:

• Results: We will send your household a letter (by mail or electronically) with the PFAS results in samples from your home.

• Privacy: All personally identifiable information (PII) (such as name, address, date of birth) gathered for the PFAS sampling is private and will not be made publicly. This information is protected according to federal and state laws regarding privacy protection. Only trained and authorized project staff will be allowed to look at information that can identify you. We will keep all of the information in a secure, locked database or file at all times. In accordance with CDC/ATSDR’s policy regarding data access, sampling results that do not include PII may be used by public health researchers for approved research purposes.

• Voluntary Participation: Participation in this investigation is completely voluntary. Even if you decide to allow your child/ward to take part, you are free to quit the investigation at any time. If at any time in the future, you would like to have your samples destroyed or removed from the assessment, please call Karen Scruton at 770-488-1325.

Parental Permission Form

By marking the check boxes below and signing this form, you are confirming that you understand the goals of the exposure assessment, and that you agree, of your own free will, to let your child/ward participate. You are also confirming you will allow the project staff to collect, store, and share the information gathered for the EI as described above. You will receive a copy of this form for your records.

I agree to allow my child/ward to complete the personal questionnaire or I will complete it for them to the best of my ability, if they are younger than 12 years old.

 Yes  No

I agree to allow the blood and environmental samples (tap water and dust, if applicable) for my child/ward, collected during the EA, to be used to evaluate the EI sampling results.

 Yes  No

I understand that my household will receive the results of the environmental sampling in a letter (electronically or by mail).

 Yes  No

I agree that my household’s PFAS environmental sampling test results may be shared with other federal, state, and local environmental and health agencies. Identifying information will be protected to the extent possible by law should you choose to share your child/ward’s results with other federal, state, or local agencies.

 Yes  No

I agree to let CDC/ATSDR keep my child/ward’s contact information and contact me in the future for possible follow-up studies (may be research or non-research studies).

 Yes  No

Parent/Guardian’s Name:__________________________________________________________

(Printed)

Parent/Guardian’s Signature:________________________________________________________

Child/Ward Name and Age:

____________________________________________

Respondent ID No:

Date Signed:__________________________________________________________________________

Street Address: ______________________________________________________________________

City: _____________________________________________ State: ________ Zip: ___________

Phone number (area code): __________________________________

Project Representative’s Name:____________________________________________________________

(Printed)

Project Representative’s Signature:_________________________________________________________