NYC-WTC_000199621

NYC 9/11 Public Portal Document

Results

When we finish this investigation, NYCDOH will prepare a written report that discusses the findings. The report will be available to the public but will not identify individual buildings or units. Your name or address will not be in any report.

NYCDOH will provide you with the results of your dust and air samples along with an explanation of their meaning.

We will not make individual sampling results or individual questionnaire information available to the public but may share them with other local, state, or federal health or environmental agencies. In addition, we will share results from the sampling for individual residences with building management. We will protect your confidentiality according to local, State, and Federal laws.

Questions

Before you decide whether to accept this invitation to take part in this investigation, please ask any questions that might come to mind now. Later, if you have questions about the investigation, please contact the investigator, Chris D’Andrea, New York City Department of Health, (212) 788-4285. If you have questions about your rights as a participant, please contact Stephen Titus, PhD(C), MPH, Chairperson or Berton Freedman, MPH, Vice Chairperson at the New York City Department of Health’s Institutional Review Board at 212-442-3385 or 347-538-0089. We will give you a copy of this consent form to keep.

What Else Do I Need to Know?

If you have any symptoms of illness which you think may be related to the dust or air in your home, you should contact your personal physician.

I have read this consent form and I have been given a copy of this form. I agree to participate in this investigation.

Resident Signature Date

CITY_21MC100_003034954

NYC-WTC_000199622