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Form Approved

OMB No. 0923-XXXX

Exp. Date xx/xx/20xx

Attachment 4i. Synthetic Turf Field Sampling Collection Form

Study ID Number _______________________

Sample Collection Date _______________________

Collector ID _______________________

Crumb Rubber Samples Collection – For Metals (Plastic Containers)

Field Location	Sample Collected
S1	Yes No
S2	Yes No
S3	Yes No
S4	Yes No
S5	Yes No
S6	Yes No
S7	Yes No

Crumb Rubber Samples Collection – For Organics (Glass Containers)

Field Location	Sample Collected
S1	Yes No
S2	Yes No
S3	Yes No
S4	Yes No
S5	Yes No
S6	Yes No
S7	Yes No

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).

Crumb Rubber Samples Collection – For Microbes (Sterile Plastic Containers)

Field Location	Sample Collected
S1	Yes No
S2	Yes No
S3	Yes No
S4	Yes No
S5	Yes No
S6	Yes No
S7	Yes No

Particle/Dust Sample Collection – For Metals (Plastic Container)

(collected as a combined sample across the seven locations)

Field Location	Sample Collected
S__	Yes No

Sample Collection Locations

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