NYC-WTC_000199633

NYC 9/11 Public Portal Document

New York City Department of Health

Consent for Access to Property For Environmental Sampling

The New York City Department of Health is conducting a pilot investigation to characterize the makeup of airborne and settled dust in residential areas around the World Trade Center (WTC) site. Participation in this investigation is voluntary. Your participation will help to determine if the contents of air and dust inside of your property can cause eye, nose, and throat (ENT) irritation. It will also assist in determining if more chronic health concerns from airborne asbestos or silica should be investigated further.

This investigation involves collecting indoor environmental samples (air and settled surface dust) from your property. The samples will be analyzed for the following;

Indoor air; Crystalline silica and asbestos that can be inhaled dust that can be inhaled will be tested for irritants (gypsum, mica, calcite)

Indoor settled surface dust will be tested for: Asbestos, crystalline silica, pH, gypsum, mica, calcite, and magnesium (a tracer to WTC collapse)

These tests will help to determine if you or other residents are being exposed to airborne materials at levels that are causing ENT irritation, or could cause long-term respiratory problems.

Participation

Furnishing any information is voluntary, and you may choose to stop participation at any time, even after signing this consent form. If you choose not to participate, or to stop at any time, there will be no penalty.

You will be requested not to smoke, burn candles or incense, fry foods or perform any other activities causing smoke. You will be requested not to do any cleaning during the day while sampling is taking place. You should be present during the sampling and may freely move about your home. If you leave, you should arrange for adequate security for your home during that time period. You will be asked to continuously run the fan on your heating, ventilating, and air conditioning system. If this cannot be done, we ask that you run a large fan to keep air circulating.

You have a right to request photo identification from all persons who gain access to your property for the purpose of sample collection or establishing continuous operation of the heating, ventilating, and air conditioning system.

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NYC-WTC_000199633