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Appendix 24-2

USGS Example of Parental Consent Letter for LD Testing

   

1.   __________________________ has my permission to participate in the U.S. Geological Survey’s Lyme
            (enrollee name)

   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


SM 445-2-H Table of Contents || Handbooks || Survey Manual Home Page
U.S. Department of the Interior, U.S. Geological Survey, Reston, VA, USA
URL: http://www.usgs.gov/usgs-manual/handbook/hb/445-2-h/app20.html
Contact: APS, Office of Policy and Analysis
Content Information Contact: wrmiller@usgs.gov
Last modification: 28-Aug-2002@17:03 (kk)