Activity 2 - Exposure Measurement Form

Collections Related to Synthetic Turf Fields with Crumb Rubber Infill

Att5f Exposure Measurement Form

Activity 2 - Exposure Measurement Form - (Adult/Adolescent Facility Users)

OMB: 0923-0054

⚠️ Notice: This form may be outdated. More recent filings and information on OMB 0923-0054 can be found here:

2016-08-12 - No material or nonsubstantive change to a currently approved collection
2016-08-04 - No material or nonsubstantive change to a currently approved collection

Document [docx]

Download: docx | pdf

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Form Approved

OMB No. 0923-XXXX

Exp. Date xx/xx/20xx xxxxxx/xx/xx/20xx

Attachment 5f. Exposure Measurement Form

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Study ID Number _______________________

Sample Collection Date _______________________

Collector ID _______________________

Field Air Samples

(mark collection locations on field chart)

Sample Type	Field Location A Sample Collected	Field Location B Sample Collected	Background Location Sample Collected
VOC Sample	Yes No	Yes No	Yes No
SVOC Sample	Yes No	Yes No	Yes No
Particle Sample	Yes No	Yes No	Yes No

Field Wipe Samples

(mark collection locations on field chart)

Sample Type	Field Location A Sample Collected	Field Location B Sample Collected	Field Location C Sample Collected
SVOC Sample A	Yes No	Yes No	Yes No
SVOC Sample B	Yes No	Yes No	Yes No
Metals Sample	Yes No	Yes No	Yes No

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ATSDR estimates the average public reporting burden for this collection of information as 3 hours per response, including the time for reviewing instructions, searching existing data sources, gathering and maintaining the data needed, and completing and reviewing the collection of information. An agency may not conduct or sponsor, and a person is not required to respond to collection of information unless it displays a currently valid OMB control number. Send comments regarding this burden estimate or any other aspect of this collection of information, including suggestions for reducing this burden to CDC/ATSDR Reports Clearance Officer; 1600 Clifton Road, MS D-74, Atlanta, GA 30333, ATTN: PRA (0923-XXXX).

Field Dust Samples

(mark collection locations on field chart)

Sample Type	Field Location A Sample Collected	Field Location B Sample Collected	Field Location C Sample Collected
SVOC Sample	Yes No	Yes No	Yes No
Metals Sample	Yes No	Yes No	Yes No
Particles Sample	Yes No	Yes No	Yes No

Sample Collection Locations

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Study ID Number _______________________

NOTE: Use one form for each participant if multiple participants are part of a sampling event

Personal Air Sample – VOCs

Sample Type

Sample Collected

Personal

Yes No

Dermal Dosimeter Samples - SVOCs

Sample Type	Sample Collected
Location 1 – Hand	Yes No
Location 2 – Arm	Yes No
Location 3 - Leg	Yes No

Dermal Dosimeter Samples - Metals

Sample Type	Sample Collected
Location 1 – Hand	Yes No
Location 2 – Arm	Yes No
Location 3 - Leg	Yes No

Urine Samples

Sample Type

Sample Collected

Pre-Activity

Yes No

Post-Activity

Yes No

Blood Samples

Sample Type

Tube 1 Collected

Tube 2 Collected

Pre-Activity

Yes No

Post-Activity

Yes No

File Type	application/vnd.openxmlformats-officedocument.wordprocessingml.document
Author	Zartarian, Valerie
File Modified	0000-00-00
File Created	2021-01-23

Activity 2 - Exposure Measurement Form

Collections Related to Synthetic Turf Fields with Crumb Rubber Infill

Att5f Exposure Measurement Form