This information will help you and the testing team to understand potential routes of exposure to arsenic. The information in this form is confidential unless you authorize its release. Name of child giving hair sample Date hair sample given Name of person filling out questionnaire and relationship to child: 3. Do you or any adults in your home work or are employed with: 4. Has your child eaten fish, shellfish, or seaweed (including kelp) during the past two weeks? 6. Have you or do you give your child herbal preparations or teas? Yes No Name of preparation 7. Does your child (now or in the past) eat non-food items (dirt, snow, paper, etc.) 8. If your answer to No. 7 is "yes", please name the item and estimate how much his/her daily consumption is P:AMU-0[hairsamplingquestionnaire 77-354 D-8 The American University has decided to make testing for potential arsenic exposure available to children who have attended the Child Development Center (CDC) within the past twelve months. The testing involves sampling and chemical analysis of a sample of hair from each child. This testing will be performed at no cost to you. University has retained the services of an independent consulting firm, Washington Occupational Health Associates (WOHA), who will collect the actual samples. The signature of a parent or legal guardian on the attached consent form will authorize WOHA to conduct the test and release the results to you. A technician will cut a hair sample of about 0.5 grams from the back of the head (nape of the neck) of each child using a pair of scissors. This mass of hair is equal to a bundle of hair about 1⁄4 inch in diameter and 2 inches long. There is no physical pain or discomfort associated with this procedure. This hair sample will be tested only for arsenic. Participation in this testing is totally voluntary and you may choose to stop at any time, even after signing this consent form. WOHA will provide you with your child's test results and an explanation of their significance. The results will be mailed to you. The results of this test are an indicator of possible exposure to arsenic. These test results are not an indicator of disease and cannot be used to predict the future occurrence of disease. Individual test results will not be made available to American University or to the public and will be maintained under absolute confidentiality unless parental permission is granted for their release. Summary statistics of the tests that do not reveal individual results will be made available to American University, the Agency for Toxic Substances and Disease Registry (ATSDR), and the DC Department of Health to determine if any further public health intervention steps are necessary. We want to stress that these statistics are summaries only, and that your confidentiality will be maintained. For further information, please call the American University information line at (202) 885-2020. P:AMU-01\consentforhairtesting |