1. __________________________ has my permission to participate in the U.S. Geological Survey’s Lyme
Disease Medical Surveillance Program.
2. I understand that the program may include a screening test both prior to and after exposure to tick-infested areas.
3. I also consent to a test in the event my son/daughter develops symptoms of Lyme Disease.
4. I understand the screening test involves blood extraction, and that the test will be conducted by qualified medical personnel selected by the USGS.
5. Payment for the screening test will be made by the USGS.
6. Results of the screening will be subject to the Privacy Act of 1974, 5 U.S.C. 552a.
Date Print or type name of parent/guardian
Signature of parent/guardian