Assent Form

Appendix B5: Assent Form

PFAS Environmental Sampling at Select Exposure Assessment Sites

Assent Form (12-17 years of age)

Reading Level: 7.0

We are doing a study on chemicals called PFAS. PFAS stands for Per- and Polyfluoroalkyl Substances. Your parents have said that you could take part in the study. We want to give you some information about it so you can decide whether you want to participate.

Two years ago you were part of a study where we took samples of your blood and urine and tested them for PFAS. You also completed a questionnaire about your potential exposure to PFAS. PFAS was found in the drinking water in your community and we wanted to find out if exposure to PFAS in the water may result in higher levels of PFAS in the body.

Although drinking water is one way to be exposed to PFAS, there are also other ways. Many consumer products contain PFAS and you could be exposed if you use them or come into contact with them. We are asking you to complete another questionnaire that asks questions about your use of products and food that may contain PFAS to see if you may have been exposed.

You will not be asked to give us a sample of blood or urine.

We hope you will agree to be part of this investigation. 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 being in this investigation.

If you agree to participate, please sign at the end of the form. The personal exposure questionnaire should take about 15 minutes to complete.

It is your choice whether to be in this investigation. There is no penalty if you choose not to be in this assessment. You may stop being in this assessment at any time. If at any time in the future, you would like to have your answers to the questions removed from the investigation, please call Karen Scruton at 770-488-1325.

Project Name: _______________________________________________________________________

Project Coordinator’s Name:____________________________________________________________

(Printed)

Project Coordinator’s Signature:_________________________________________________________

As described above, you are being asked to participate in an environmental sampling investigation. You may participate by indicating your assent to the items below. You may assent to all, some, or none of the items.

To be in this assessment, please sign your initials in the box next to each item you agree to.

I agree to fill out the personal exposure questionnaire.

	I agree to let the blood sample collected during the EA be used to evaluate the environmental sampling results.

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

I have read the assent form (or someone has read it to me), and I agree to be in this environmental sampling investigation and complete the questionnaire. My initials above show which parts of the assessment I agree to participate in.

Participant’s Name:____________________________________________________________________

(Printed)

Participant’s Signature:_________________________________________________________________

Date Signed: ___________________________________________________ `

Street Address: ___________________________________________________

City: ______________________________ State: ______ Zip: __________

Phone number (area code): ___________________________________