Consent for environmental sampling

Appendix B5: Environmental Sampling Consent Form

Form Approved

OMB No. 0923-xxxx

Exp. Date xx/xx/20xx201x

PFAS Exposure Assessment, Environmental Sampling

Head of Household Consent Form

Flesch-Kincaid Reading Level: 9.7

ATSDR estimates the average public reporting burden for this collection of information as 10 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).

You are invited to take part in an assessment that will measure the levels of per- and polyfluoroalkyl substances (PFAS) in your drinking water and indoor dust. We are trying to determine the levels of PFAS in the homes of people who may have consumed contaminated drinking water while living near (Insert name of city/town/place here).

This letter will explain the procedures, risks, and benefits of our exposure assessment to help you decide if you will take part.

Procedures for the Exposure Assessment

First, we will collect a drinking water sample from the source in your home you and your family most often drink water (e.g. kitchen tap). Then, we will collect indoor dust from up to three locations inside your home.

We will label your water and dust samples with a code only. Only the project coordinator will be able to identify whose house the samples are from.

We will send your water and dust samples to [insert names of laboratory] to measure the levels of PFAS. There will be no charge for the sample collection or the laboratory analysis. At the end of the exposure assessment, we will mail your test results to you at the address you provided today. If you would like to talk with an exposure assessment staff person about your results, you can free of charge.

Methods to measure PFAS in water and dust samples are still being developed and improved. It is possible that new tests will be developed in the future that will increase our ability to measure PFAS in water and dust. We would like to keep your water and dust samples so that scientists can test for more things if new tests are developed. To do this, we need your permission.

The Risks of Taking Part in Our Exposure Assessment

You might be inconvenienced. It will take about 15 minutes for us to collect samples from your home. We may need to run water from your well which might lower the volume of water in your well for a brief recharge period.

The Benefits of Taking Part in Our Exposure Assessment

Your participation in this assessment will help us understand the range of PFAS exposure and possible exposure sources in your community. You will find out the levels of PFAS in your home. If we find PFAS levels that may be of concern for your health, we will recommend things you can do to reduce your exposure.

Additional Information:

• Results: We will send you a letter with your PFAS level results along with how they compare to any available health based guidelines.

• Privacy: All personally identifiable information (PII) (such as name, address, date of birth) gathered for the exposure assessment is private and will not be publically released. This information is protected to the extent possible by (insert name of state here) and federal laws and regulations related to privacy protection. Only trained and authorized project staff will have access to information that can identify you. We will keep all of the information in a secure, locked database or file at all times. Aside from the exposure assessment team, you are the only one who will receive your individual results. 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 exposure assessment is completely voluntary. Your choice will not affect your current or future relationships with groups that are part of the exposure assessment. Even if you decide to take part, you are free to quit the exposure assessment 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 (insert name and phone number of Study coordinator).

Consent 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 participate. You are also confirming you will allow the project staff to collect, store, and share the information gathered for the exposure assessment as described above. You will receive a copy of this form for your records.

I agree to allow drinking water and indoor dust samples to be collected from my home and analyzed for PFAS.

 Yes  No

I understand that I will receive my environmental sampling results by mail. I will be able to compare some of my results with health advisory levels.

 Yes  No

I agree that my environmental sampling results may be shared with other federal, state, and local environmental and health agencies and local water utilities. Your identifying information will be protected to the extent possible by law should you choose to share your results with other federal, state or local agencies.

 Yes  No

I agree that my indoor dust and water samples may be saved for additional PFAS-related analysis in the future.

 Yes  No

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

 Yes  No

Participant’s Name:____________________________________________________________________

(Printed)

Participant’s Signature:_________________________________________________________________

Date Signed:________________________________________________________________________

Street Address: _______________________________________________________

City: ________________________________ State: ________ Zip: ________

Phone number (area code): __________________________________

Project Representative’s Name:____________________________________________________________

(Printed)

Project Representative’s Signature:_________________________________________________________