0920-1173 Screening Survey

Attachment C

Screening Survey

Form Approved

OMB No. 0920-1173

Exp. Date 03/31/2020

Screening Survey

Exposure to Arsenic and Uranium in Private Well Water

Time interview began: _ _: _ _ AM / PM Date ___________

Name of Respondent: _____________________ _____________________________

Last Name First Name MI

Mailing/Telephone information (label):

Additional Contact information

Subject Name, ID, Collection Checklist

First name(s)
Subject form labels	Subject Form Label 1

CDC estimates the average public reporting burden for this collection of information as 30 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 (0920-1173).

Hello,

My name is <name>. The Centers for Disease Control and Prevention and the U.S. Geological Survey (USGS) are working with the <state, department> to better understand exposure to naturally-occurring arsenic and uranium from private well water. <State> has told us that there is limited or no information about arsenic and/or uranium in well water in your area of the state. We want to test for the amount of arsenic and uranium in the water from private wells in your area. We also would like to know how arsenic and uranium in private well water is related to arsenic and uranium in people’s urine, so we will also collect a tap water sample and ask one adult in your household to give us a urine specimen and answer some questions about things that might affect your exposure to arsenic and uranium (such as foods you eat or hobbies you have).

Please be assured that CDC will take all necessary steps to protect members of your community from COVID-19. The exposure assessment will be conducted following all state, local, and CDC guidelines in place at the time the exposure assessment is conducted. CDC team members will be monitored twice daily for fever and any COVID-19-related symptoms and will wear surgical masks and gloves to ensure the protection of participants. Participants will be asked to always wear a face covering or mask if you will be interacting with exposure assessment personnel. If you do not have a mask, one will be provided to you. If you are unable to wear a mask for medical reasons, please let us know.

Your participation in this investigation will greatly enhance our understanding of where arsenic and uranium are in the ground water that supplies private wells. Are you willing to volunteer for the investigation?

If no: OK. Thank you.

If yes: Thank you very much.

I need to ask you a few more questions to make sure you are eligible to be in the investigation:

Yes No (check correct box)

□ □ Are you at least 18 years old? If not, is there an adult in your household

who may be willing to participate and complete this screening survey?

□ □ Do you live in a household with a domestic private well? (versus being on

municipal water)

□ □ Does your household use well water for drinking or cooking?

□ □ Do you know whether your well water is treated before it is used in the home? If so, explain how?

□ □ Will you allow investigation representatives to collect a well water sample?

□ □ Are you willing to collect a tap water sample from your kitchen faucet?

□ □ Are you willing to provide a urine specimen?

□ □ Are you willing to refrain from eating fish or shellfish for 3 days prior to

providing a urine specimen?

□ □ On those same 3 days, are you willing to keep a food log?

□ □ Are you willing to complete a survey by phone about your general

information, your household water source and use, and other things that

might affect your exposure to chemicals that may be in your well water?

We will not ask you any questions about your health, but we will ask

about types of medications, food supplements, and ayurvedics that you

might be taking.

<if all questions are yes except for the pregnancy question> Thank you. You are eligible to be in the investigation!

We will send you a copy of the investigation consent form in the mail and will bring a hard copy for you to sign when we visit your home. We will also mail a food log with instructions for you to begin completing 3 days prior to us visiting your home. In order to accurately measure arsenic and uranium in urine, we need you to collect your first morning urine. We will mail instructions for collecting the urine sample and a urine specimen cup for you to use the morning of the day we come to your home. During the home visit, we will collect two water samples and ask you to complete a survey about how you use your water and possible other sources of chemicals.

<if otherwise> Thank you, but I am sorry, we need people to (choose appropriate option) <be 18 years old OR live in a household with a private well OR know whether their drinking water is treated OR use the water for drinking and cooking OR allow us to collect water samples OR provide urine specimen> to be in our investigation.

OK, let’s go ahead and set up an appointment for us to do our investigation activities.

For well water and tap water sampling, urine collection, and survey administration: We’ll need about an hour to collect the water samples and do the survey.

Can you give me some good times between <date> and <date> when we can come to your home?

Possible dates and times:

Date	Time

Thank you. We have time to come to your home on <date> at <time>. Will that be OK?

If yes: Thank you very much.

If no: Try another date and time.

Thank you. Please complete your 3-day Food Log beginning on <date 3 days before scheduled appointment> and collect your urine specimen first thing in the morning on <date>. We will call you the day before the appointment to remind you that we will be coming to your home