Safe Jobs Healthy Families - Consent form for use of information and access to state records

Please fill out all applicable information and check all squared boxes that are true.

My name is

I am the mother of

Who was born on

Month

Day

Year

When I was living at the following address

I now reside at

When I was pregnant with

I worked in electronics assembly/ semiconductor fabrication in Santa Clara County

Yes

No

I worked

Day shift

Swing shift

Night shift

The company I worked for was called

it was located in the City of

I got to work by

Car

Carpool

Public Transportation

I recall the following names of supervisors in my work area

My job involved being around cleaners and solvents

Yes

No

My job involved being around soldering processes

Yes

No

I was paid this per hour

Please check all that are true

I was never given a respirator – only paper masks

I was not given any warnings about working in this job

I was never told that working in this job while pregnant could be dangerous

Next two questions go together

My supervisor named

knew I was pregnant but never said or did anything to protect me or my child from chemical exposure

I worked at this job until approx. this many days from my due date

After my child was born I stayed home to provide full-time care for this many months

After giving birth

I did return to this job

I did not return to this job

My child looked normal at birth but he/she seemed slow in learning many things

My child started kindergarten at age

The kindergartens name was

The school address was

After a while my child’s teachers told me that my child was having problems keeping up in class and was assigned to a special education class. I believe this was when my child was this many years old

My child stayed in special education until age

My child’s teachers did a lot help but my child could never get the skills needed to have a job or live independently

After my child graduated from special education he/she lived at home for this many year(s)

My family got financial help from the State of California to assist us with trying to meet my child’s special needs.

We also got regular help from in-home support service workers and/or other state workers with experience helping individuals with intellectual disabilities.

My child also attended day-away programs on a regular basis for about years; he/she was driven to the program and brought home and seemed to enjoy the activities at the programs a lot. I recall these names and locations of these programs.

Consent

I hereby give my consent for the Safe Jobs Healthy Families research team to have access to the maternal occupation and industry information on the the research version of my child, named above, birth certificate.

I also consent to Safe Jobs Healthy Families use of (a) the information in this form, (b) information the research version of my child’s birth certificate and (b) any information I provide SJHF via interview, text or email in support of its investigation of the number of children in SCC who have received special education and other publicly-funded services due to their intellectual disability who are the offspring of electronics workers

First name

Last name

Phone

Date

Month

Day

Year

Additional Contact Info

If at any time I cannot be reached, please contact the following person(s) so they can get a message to me

Name

Phone

Name

Phone