0923-0048 Environmental Sampling Collection Form - Adult (Robust)

Appendix D2: Household Environmental Sample Collection Form – Robust Sampling

Form Approved

OMB No. 0923-0048

Exp. Date 04/30/2022

ATSDR estimates the average public reporting burden for this collection of information as two hours per response, including the time for reviewing instructions, searching existing data/information sources, gathering and maintaining the data/information 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 a 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 Information Collection Review Office, 1600 Clifton Road NE, MS D-74, Atlanta, Georgia 30333; ATTN: PRA (0923-0048).

Date and Time of Sample Collection: ______________________________________

Address of Sample Collection: ___________________________________________

Samples Collected

Indoor Air

Indoor Air – Sample ID _________________________________________

Indoor Air Sample Location Description __________________________

Indoor Air Sample Start Date/Time __________________________

Indoor Air Sample End Date/Time __________________________

Flow Rate Data

Measurement 1_____________________________

Measurement 2______________________________

Measurement 3______________________________

Average_____________________________________

Indoor Air Duplicate Sample Start Time __________________________

Indoor Air Sample End Date/Time __________________________

Flow Rate Data _____________________________

Measurement 1_____________________________

Measurement 2______________________________

Measurement 3______________________________

Average_____________________________________

Indoor Air Humidity (%) _______________________________________

Indoor Air Temperature (°F) ______________________________

Dust - Filtered

Indoor Dust (Filtered Cassette) 1 (PFAS Sample)– Sample ID _________________________________

Indoor Dust (Filtered Cassette) 1 Sample Location Description __________________________

Indoor Dust (Filtered Cassette) 2 (FTOH or TOF Sample)– Sample ID _____________________________

FTOH / TOF (circle one)

Indoor Dust (Filtered Cassette) 2 Sample Location Description __________________________

Indoor Dust (Filtered Cassette) – Duplicate Sample ID _______________________________

none / PFAS / FTOH / TOF (circle one)

Dust - Bulk

Indoor Dust (Bulk) – Sample ID ________________________________________________

Indoor Dust (Bulk) Sample Description (indicate vacuum type) ______________________________

Indoor Dust (Bulk) – Duplicate Sample ID_________________________________________

Surface Wipe

Location #1 Surface Wipe Location Description ___________________________________

Location #1 Surface Wipe #1 – Sample ID _________________________________________

Location #1 Surface Wipe #2 – Sample ID _________________________________________

Location #1 Surface Wipe #3 – Sample ID _________________________________________

Location #1 Surface Wipe #4 – Sample ID _________________________________________

Location #1 Surface Wipe Duplicate – Sample ID _________________________________________

Location #2 Surface Wipe Location Description ___________________________________

Location #2 Surface Wipe #1 – Sample ID _________________________________________

Location #2 Surface Wipe #2 – Sample ID _________________________________________

Location #2 Surface Wipe #3 – Sample ID _________________________________________

Location #2 Surface Wipe #4 – Sample ID _________________________________________

Location #2 Surface Wipe Duplicate – Sample ID _________________________________________

Soil

ISM Soil – Sample ID ________________________________________________

ISM Soil Sample Location Description (e.g., the corners of the decision unit)

___________________________________________________________________________

ISM Soil – Replicate Sample #1 ID ___________________________________

ISM Soil Replicate Sample #1 Location Description (relative to the original sample)

___________________________________________________________________________

ISM Soil – Replicate Sample #2 ID ___________________________________

ISM Soil Replicate Sample #2 Location Description (relative to the original sample) ________________________________________________________________

Silicone Wristbands

Wristband for PFAS Sampling – Sample ID#1 ___________________________________________

Wristband for FTOH or TOF Sampling – Sample ID#2 __________________________________________ FTOH / TOF (circle one)

List of Observations to be made by sample team:

Observations to be made in all EI homes:

• Housing Type:

Detached single family home ______

Mobile home ______

Apartment/Condo/Townhouse ______

Detached duplex home ______

Other: ___________________________

• Number of floors in home: ___________

• Number of bedrooms in home: __________

• General condition of the home (e.g., peeling paint): Good ___ Fair ___ Poor ___

• Material used for the kitchen counters: _________________________________

• General age and condition of the soft furniture in the home:

New/pristine _____ Typical _____ Old/worn _____

• Approximate percentage of floor types in room(s) where filter dust samples are collected:

Room 1 Room 2

Hardwood _______% _______%

Tile _______% _______%

Laminate _______% _______%

Carpet _______% _______%

Vinyl _______% _______%

Other: ____________________________ _______% _______%

• Number of total person-seats of fabric covered and/or upholstered furniture in room(s) where filter dust samples are collected:

Room 1 ______________

Room 2 ______________

Additional observations to be made in homes with indoor air and soil sampling:

• Estimated height of ceilings: ______________________________ft

• Does the home have a fan coil for air conditioning (indicating central air conditioning):

Yes________________ No____________________

• Does the home have air conditioning units in a window: Yes_______ No_________

• If Household Question Q13 is not answered, estimate home square footage of living space from interior or exterior measurements, if feasible.

Estimated square footage: ________________ft2

• Does the home have a basement: Yes ____ No _____

If yes, is the basement used as living space: All ____ Some _____ None _____

If yes, what is the approximate percentage square footage as compared to the floor above: _________

• Does the home have an attic: Yes ____ No _____

If yes, is the basement used as living space: All ____ Some _____ None _____

If yes, what is the approximate percentage square footage as compared to the floor below: _________

• Describe type, extent, and estimated distance from participant home for trees, buildings, or other possible sheltering on each side of the home, including estimated height or number of building stories (this information may be entered on the building sketch):

Side 1:_____________________________________________________________________

Side 2:_____________________________________________________________________

Side 3: _____________________________________________________________________

Side 4:______________________________________________________________________

• What siding materials are used on the exterior of the home:

Brick

Vinyl

Wood

Cement board

Stucco

Shingles

Other: ________________________________

• What is the overall condition of the siding: Good ___ Fair ___ Poor ___

Data Collection Technician: ____________________________ _________________________________

Printed Name Signature

Sketch Location of Filtered Dust, Surface Wipe, and Air Samples Collected Inside the Home:

Sketch Decision Unit for ISM Soil Sample with Grid Lines:

Notes:

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Outdoor Air Sampling Form

Sample Location Description______________________________________________

Sample 1: Low Flow Sample – 7 day

Outdoor Air – Sample ID _________________________________________

Outdoor Air Sample Start Date/Time _______________________________

Outdoor Air Sample End Date/Time ________________________________

Flow Rate Data ________________________________________________

Outdoor Air Humidity (%) ________________________________________

Outdoor Air Temperature (°F) ____________________________________

Sample 1: Low Flow Sample – 7 day

Outdoor Air – Sample ID _________________________________________

Outdoor Air Sample Start Date/Time _______________________________

Outdoor Air Sample End Date/Time ________________________________

Flow Rate Data ________________________________________________

Outdoor Air Humidity (%) ________________________________________

Outdoor Air Temperature (°F) ____________________________________

Sample 1: High Flow Sample – 7 day

Outdoor Air – Sample ID _________________________________________

Outdoor Air Sample Start Date/Time _______________________________

Outdoor Air Sample End Date/Time ________________________________

Flow Rate Data ________________________________________________

Outdoor Air Humidity (%) ________________________________________

Outdoor Air Temperature (°F) ____________________________________

Produce Sample Collection Form

Sample Number	Sample ID	Date and Time of Sample Collection	Sample Description (type of produce, where grown, organic / not organic)	Market Name/Location	Notes (packaging information)