Thank you for participating in our water quality testing program. We are conducting this testing as part of recovery and resiliency efforts following Hurricane Helene, to help ensure safe water access in Western North Carolina.

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Please read the following information and provide your consent.

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Purpose of Testing

The purpose of this testing is to identify any contaminants (such as E. coli or coliform bacteria) in your household water supply. This information helps us support your household and better understand broader water quality concerns in the region.

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Use of Information

• Test results may be used in summary form to inform local government, public health agencies, donors, and community partners.

• No personally identifiable information (such as your name or address) will be shared publicly or with outside organizations unless you give explicit permission.

• Your individual test results may help us refer you to programs or resources that can assist with water system improvements.

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Voluntary Participation

• Participation in this testing is voluntary.

• Testing is provided at no cost to you.

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Confidentiality

• All personal information will be kept confidential and stored securely.

• Only authorized project staff will have access to individual household data.

• Any shared data will be aggregated or anonymized to protect your privacy.

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Consent Acknowledgment

By checking the box on the form, I agree to the use of testing information below, and confirm that I:

• Understand the purpose and use of the water quality testing program.

• Consent to my water sample being tested.

• Allow my non-identifiable water quality results to be used in reports or shared with relevant public agencies or donors.