Field User Eligibility Screening Script

Form Approved

OMB No. 0923-0058

Exp. Date 08/31/2018

Attachment 4b. Field User Eligibility Screening Script

The purpose of the exposure characterization study is to determine how people might be exposed to chemicals in the tire crumbs on synthetic turf fields. We need synthetic turf field users to:

1. Respond to a questionnaire to provide information about the types of activities performed on these fields and

2. Participate in an exposure measurement study during an athletic or training activity on a synthetic field with tire crumb rubber infill.

EPA and ATSDR would like to recruit 60 people who engage in physical activities on synthetic turf fields with tire crumbs to fill out a questionnaire about how they use the fields. The questionnaire will ask field users about the types of activities (sports, physical education and training), how much time they spend on fields and how they come in contact with the tire crumbs on the fields. EPA and ATSDR hope to perform measurements for a subset of the people (up to 45) who fill out the questionnaire. Additionally, we will be doing a video recording on a subset of those who participate in the exposure measurements (up to 24).

ATSDR estimates the average public reporting burden for this collection of information as 5 minutes 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 (0923-0058).

To find out if you are eligible, I will read the questions to you.

If respondent is an adult, ask question #1. If respondent is the parent/guardian of a child, skip question #1 and go straight to question #2:

1. What is your age?....................................................................................................________

If greater than 18 years of age, go to question #4.

If respondent is the parent/guardian of a child:

2. What is your child’s age?........................................................................................_________

If the child is less than 7 years old, the respondent is not eligible to participate.

As your child is not at least seven years old, your child is not eligible to participate in this project. I am sorry. Thank you for your time.

If child is 7 years or older:

3. What is your child’s grade in school? _________

For respondents greater than 18 years of age and respondents that are parents/guardians of children at least seven years of age:

4. Did you (did your child) participate in activities on a synthetic turf field with crumb rubber infill during the previous year? …………………………………………

If no, respondent is not eligible to participate.

You are not eligible to participate in this project. I am sorry. Thank you for your time.

5. Would you (would your child) be willing to complete a short survey to collect information about your time and activities that might affect exposures to chemical and microbiological agents associated with synthetic turf fields?.................................................................. 

6. Would you (would your child) be willing to be recorded on video during a sports practice or play activity on a synthetic turf field with crumb rubber infill? The video would be used to collection information about how people contact the fields and field materials that might affect exposures to chemical and microbiological agents. Yes….. 

No…....

Will Not Have Eligible Activity in Study Time Frame …..

7. In addition to the survey, would you (would your child) be willing to participate in a study that measures potential chemical exposures while participating in an activity on a synthetic turf field with crumb rubber infill? This may include collecting a sample of the air that you (or your child) breathe (a small tube pinned to your/your child’s shirt), skin wipe samples, and blood and urine samples around a normal period of your (his or her) activity on a synthetic turf field. Yes….. 

No…....

Will Not Have Eligible Activity in Study Time Frame …..

8. Do you know anyone else who uses this facility and would you be willing to share their contact information?

Yes….. 

Contact Information:____________________________________________________________

No…....

If field user is willing to participate they will be provided a consent form, and staff will be available to answer any questions they may have.