Household Eligibility Screener

Appendix A3: Household Eligibility Screener

Form Approved

OMB No. 0923-xxxx

Exp. Date xx/xx/20xx

PFAS Exposure Assessment, biological sampling

Household Eligibility Screener

ATSDR estimates the average public reporting burden for this collection of information as 5 minutes per response, including the time for reviewing instructions, searching existing data/information sources, gathering and maintaining the data/information needed, and completing and reviewing the collection of information. An agency may not conduct or sponsor, and a person is not required to respond to a collection of information unless it displays a currently valid OMB Control Number. Send comments regarding this burden estimate or any other aspect of this collection of information, including suggestions for reducing this burden to CDC/ATSDR Information Collection Review Office, 1600 Clifton Road NE, MS D-74, Atlanta, Georgia 30333; ATTN: PRA (0923-xxxx).

Reading Level: 8.5

Hello, I am ______________________ from [Insert affiliation], calling on behalf of the Agency for Toxic Substances and Disease Registry, or ATSDR for short. May I please speak with the head of the household?

I would like to take about 5 minutes of your time today to invite you and the members of your household to be part of an exposure assessment. The assessment will measure chemicals called per- and polyfluoroalkyl substances, or PFAS, in the bodies of people living in your area. PFAS are a large group of man-made chemicals that have been used in industry and consumer products worldwide since the 1950s.

ATSDR is a federal public health agency that is part of the Centers for Disease Control and Prevention). It is working to understand how people living in your area have been exposed to PFAS. This will help us determine if exposure to these chemicals is a problem in your community and it will help us to design future studies to understand how these chemicals affect people’s health. To do this, we need people in this community to participate in blood and urine testing.

We are calling today because ATSDR is interested in recruiting everyone in your household who is eligible to take part in this assessment. Taking part in the exposure assessment will include signing a form agreeing to be tested, giving a blood sample, giving a urine sample, and completing a short questionnaire. ATSDR will ask questions to better understand the lab test results. The time required to participate is about 30 minutes.

According to the Privacy Act, we will protect the private information that you provide for yourself and your family. If you enroll in the assessment, we will give you a copy of our Privacy Act Statement before we get your consent to participate.

Is it okay if I ask you a few questions to see if you and other members of your household qualify to take part in the exposure assessment?

Yes No

OK, thanks a lot. You are free to answer or not answer these questions. You can also ask me any questions you have.

If ‘Yes’, Screening Questions:

1. Have you or someone in your household lived in the community full time for at least one year?

Yes No Don’t Know Refused to Answer

1. Of these people how many are 3 years old and older? _______

2. Do any of these people have a bleeding disorder that prevents them from giving a blood sample?

Yes No Don’t Know Refused to Answer

1. If ‘yes’, how many? ________

**If there are people who have lived in the community for more than one year, are older than 3, and don’t have a bleeding disorder, proceed to question 2.

2. Are you and others from your household willing to participate in the exposure assessment? This will include a blood test, urine test, and answering questions from a questionnaire.

Yes No Refused to Answer

If No: Okay, thank you for your time. Goodbye.

If Yes: Thank you very much.

All members of your household who have lived in the home for at least one year, who are older than the age of 3, and who do not have a bleeding disorder will be eligible to participate. Each individual will be given the opportunity to decide for him or herself whether or not they want to participate. We will attempt to schedule your sample collection appointment now. You will receive a letter in the mail with confirmation of your appointment time and location.

We have two additional questions.

• While at home, do you and your family members primarily drink tap water?

Yes No Refused to Answer.

• Can you please confirm the best contact information to reach you?

Name: ____________________________________________

Address: ___________________________________________________________

Phone Number: ______________________________________________________