Appendix A to Part 850 - Chronic Beryllium Disease Prevention Program Informed Consent Form
10:4.0.2.5.30.3.74.22.26 : Appendix A
Appendix A to Part 850 - Chronic Beryllium Disease Prevention
Program Informed Consent Form
I, _______ have carefully read and understand the attached
information about the Be-LPT and other medical tests. I have had
the opportunity to ask any questions that I may have had concerning
these tests.
I understand that this program is voluntary and I am free to
withdraw at any time from all or any part of the medical
surveillance program. I understand that the tests are confidential,
but not anonymous. I understand that if the results of any test
suggest a health problem, the examining physician will discuss the
matter with me, whether or not the result is related to my work
with beryllium. I understand that my employer will be notified of
my diagnosis only if I have a beryllium sensitization or chronic
beryllium disease. My employer will not receive the results or
diagnoses of any health conditions not related to beryllium
exposure.
I understand that, if the results of one or more of these tests
indicate that I have a health problem that is related to beryllium,
additional examinations will be recommended. If additional tests
indicate I do have a beryllium sensitization or CBD, the Site
Occupational Medical Director may recommend that I be removed from
working with beryllium. If I agree to be removed, I understand that
I may be transferred to another job for which I am qualified (or
can be trained for in a short period) and where my beryllium
exposures will be as low as possible, but in no case above the
action level. I will maintain my total normal earnings, seniority,
and other benefits for up to two years if I agree to be permanently
removed.
I understand that if I apply for another job or for insurance, I
may be requested to release my medical records to a future employer
or an insurance company.
I understand that my employer will maintain all medical
information relative to the tests performed on me in segregated
medical files separate from my personnel files, treated as
confidential medical records, and used or disclosed only as
provided by the Americans with Disability Act, the Privacy Act of
1974, or as required by a court order or under other law.
I understand that the results of my medical tests for beryllium
will be included in the Beryllium Registry maintained by DOE, and
that a unique identifier will be used to maintain the
confidentiality of my medical information. Personal identifiers
will not be included in any reports generated from the DOE
Beryllium Registry. I understand that the results of my tests and
examinations may be published in reports or presented at meetings,
but that I will not be identified.
I consent to having the following medical evaluations:
/ / Physical examination concentrating on my lungs and breathing /
/ Chest X-ray / / Spirometry (a breathing test) / / Blood test
called the beryllium-induced lymphocyte proliferation test or
Be-LPT / / Other test(s). Specify: Signature of Participant: Date:
______
I have explained and discussed any questions that the employee
expressed concerning the Be-LPT, physical examination, and other
medical testing as well as the implications of those tests.
Name of Examining Physician: Signature of Examining Physician:
Dated: ______