Youth Exposure Measurement

Characterization of Exposure Potential during Activities Conducted on Synthetic Turf with Crumb Rubber Infill

Att4f Exposure Measurement Form_Final clean

Youth Exposure Measurement

OMB: 0923-0058

Document [docx]
Download: docx | pdf


Shape1

Form Approved

OMB No. 0923-XXXX

Exp. Date xx/xx/201x



Attachment 4f. Exposure Measurement Form


Shape2

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




Shape3

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


Shape4

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

Yes No

Post-Activity

Yes No

Yes No



File Typeapplication/vnd.openxmlformats-officedocument.wordprocessingml.document
AuthorZartarian, Valerie
File Modified0000-00-00
File Created2021-01-22
© 2025 OMB.report | Privacy Policy