Hoosick Falls Biomonitoring Contact Information Form
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1NEW YORK STATE DEPARTMENT OF HEALTH
CONTACT INFORMATION FORM TO REQUEST BIOMONITORING
Biomonitoring Project to Assess Exposure to Perfluorooctanoic Acid (PFOA):
Hoosick Falls Area, Rensselaer County, NY
•
The New York State Health Department (NYS DOH) will be collecting blood samples as part of
a PFOA biomonitoring study for people who live in or near Hoosick Falls. People who participate
will be asked to fill out a consent form and a questionnaire, and get blood drawn.
•
NYS DOH will use this information to contact you about upcoming blood testing events.
•
NYS DOH staff may contact you by telephone, email, or mail.
•
Biomonitoring information and related events will be posted at
•
You can also call the NYS DOH at 518-402-7950 and we can take this information by
telephone.
•
If you already have provided this information to someone at the NYS DOH, we have your
request, and you do not need to fill out this form.
Last Name:
___________________________________________
First Name (of person filling out form):
___________________________________________
Date of Birth: ________/__________/__________
Gender:
M
F
Number of Household Members Requesting Biomonitoring:
__________
Adults (18 years and older)
___________ Children (17 years and younger)
Residential Address
Street:
____________________________________________
City:
_________________________
State: ________
ZIP:
______________
Phone:
(____)________-__________
(____)________-_________
Email:
___________________________________________
Mailing Address (if different):
Street:
____________________________________________
City:
_________________________
State: ________
ZIP:
______________
Completed forms should be sent by mail or email to:
New York State Department of Health
Email:
BEOE@health.ny.gov
Empire State Plaza, Corning Tower Room 1203 (Attn: June Moore)
Albany, NY 12237
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