Consent Form

Attachment D

Consent Form

Exposure to Arsenic and Uranium in Private Well Water

Consent Form

The Centers for Disease Control and Prevention (CDC) and the U.S. Geological Survey (USGS) are doing a water quality investigation in <state> with the assistance of your <state, agency>. This investigation will assess exposure to arsenic and uranium in drinking water from private wells in your state. Exposure to arsenic through private well water is associated with adverse health effects such as cancer and heart disease, and exposure to uranium may be associated with kidney damage. With the data from this investigation, USGS will be able to better identify areas in <state> that have high levels of naturally-occurring arsenic and uranium in groundwater. The <state, agency> will use information from this investigation to help private well owners to understand how to reduce their exposures to arsenic and uranium from well water. The Public Health Service Act (Section 301, 42 U.S.C. § 241) lets CDC collect this kind of information.

Please be assured that CDC will take all necessary steps to protect members of your community from COVID-19. The study will be conducted following all state, local, and CDC guidelines in place at the time the study is conducted. CDC team members will be monitored twice daily for fever and any COVID-19-related symptoms. Although we don’t anticipate face-to-face contact with study participants, if this does occur (e.g., when a study team member picks up water samples and urine specimens), study team members will wear surgical masks and gloves to ensure the protection of participants. Again, although we do not anticipate face-to-face contact with study team members, if that occurs, participants will be asked to always wear a face covering or mask. If you do not have a mask, one will be provided to you before you enter the facility. If you are unable to wear a mask for medical reasons, please let us know.

We would like you to volunteer to be part of this project

We ask you to take part in this water quality investigation because you get your drinking water from a private well. You can choose if you want to be in the investigation. You can stop being in the investigation at any time. During the survey, you can also refuse to answer any question. If you refuse, it will not affect any government benefits that you receive.

For this investigation, we will ask you to do these things for us

1. Complete a 3-day food log.

2. Provide a urine specimen that we will test for arsenic and uranium on the day after you complete the food log (i.e., day 4).

3. Allow us to take a water sample from your well that we will test for arsenic and uranium.

4. Collect a water sample from your in-home tap according to the instructions we will provide.

5. Complete a survey. In the survey, we will ask you questions 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.

It will take about 30 minutes for us to collect the water samples and about 10 minutes for you to provide the urine specimen. It will take about 30 minutes to complete the survey.

Privacy

• We will give you an identification (ID) number. Your ID number, not your name, will go on the water samples, your urine specimen, and your survey.

• We will keep a record of your name, address, and ID number so that we can send you the water and urine test results. CDC and USGS will keep your personal information in a password-protected computer. Your signed consent form will be kept in a locked file cabinet.

• Names and contact information of people who take part will not be used in any report.

• We will not share any of your personally identifiable information (e.g., name, address), even if requested to do that through a Freedom of Information Act (FOIA) request. Your information is protected under the FOIA exemption 6 (Information that, if disclosed, would invade another individual’s personal privacy).

• Your name and address will be deleted from our files after our report is finalized. We do not plan to recontact you for any follow-up investigations.

Risks from being in the investigation

• There are no risks to you or your family from having your well tested as part of this investigation.

• There may be a risk from having your well location and testing results in a publicly available database. To decrease this risk, we plan to report the test results by town rather than identify them individually.

• You might be inconvenienced because it will take about 60 minutes for us to collect your well water and tap water, collect your urine sample, and ask you questions. We may need to run water from the well for a brief period of time which might leave a large wet area in your yard.

• If you have any questions about this testing, you can ask us now.

• If you have any questions about this water quality investigation, you can call the USGS project leader <project leader>. XX’s number is (XXX) XXX-XXXX.

Benefits from being in the investigation

• We will provide you with the results from your urine and water tests.

• You will find out if your water contains arsenic or uranium in amounts that might be harmful to you or your family.

• If we find arsenic or uranium in amounts that may be harmful, you can contact your state Department of Health to learn about things you can do to reduce the risk of coming in contact with the chemicals. Treating your well water may be costly.

Would you like a copy of the report from this investigation?

If you would like a copy of the report, we can send you one. Please provide your email so we can send you a copy of the final published report.

__________________________________________

Email address

By signing below, you agree to take part in the investigation. You are also saying we have given you a signed copy of this consent form (we will keep the other signed consent form). If there is any part of this form that is not clear to you, be sure to ask about it.

______________________________ ___________________________

Signature Date