Form 0923-19GW Youth/Child Field Questionnaire

Form Approved

OMB No. 0923-xxxx

Exp. Date xx/xx/201x

Youth/Child Field User Questionnaire

OMB Attachment 3f

Form Approved

OMB No. 0923-xxxx

Exp. Date xx/xx/201x

Supplemental Youth/Child Field User Questionnaire

Synthetic turf field user Natural grass field user

Interviewer: I would like to ask you some questions about activities that may affect your child’s exposures to, and contact with synthetic turf fields/natural grass fields that contain crumb rubber materials.

For natural grass field users only: Interviewer: Has your child played on a synthetic turf field with crumb rubber infill in the last 48 hours? Yes No

For synthetic turf field users: Has your child participated in activities on a synthetic turf field with crumb rubber infill for at least one year? Yes No

For natural grass field users: Has your child played on synthetic turf fields with crumb rubber infill for at least one year? Yes No

Field Contact Frequency and Duration Questions

Interviewer: I have several questions about the time your child spends on synthetic turf fields/natural grass fields at this facility

(years)

B1. How long has your child been coming to this facility?

(months)

B2. Specifically on the synthetic fields/natural grass fields at this facility, what sports, physical education classes, or other activities has your child actively participated in by season (specify) over the past year?

Season		Sport		Specify Other

ATSDR estimates the average public reporting burden for this collection of information as 30 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 (0923-00xx).

* The electronic data collection/computer-assisted interview system will allow for question population based on the field user indicated.

B3. Over the past year, how many days per week by season has your child typically spent on synthetic fields/natural grass fields at this facility?

Spring		(days per week)
Summer		(days per week)
Fall		(days per week)
Winter		(days per week)

B4. Over the past year, how many hours per day by season has your child typically spent on the synthetic fields/natural grass fields at this facility?

Spring		(hours per day)
Summer		(hours per day)
Fall		(hours per day)
Winter		(hours per day)

B5. Over the past year, what was the longest period of time that your child has spent on the synthetic fields/natural grass fields at this facility during a single day?

(number of hours)

Contact Types and Scenarios per Each Type of Field Use

Interviewer: I have several questions about the kinds of activities that your child takes part in specifically on synthetic turf fields/natural grass fields installed at this facility.

For the following question, please use one of the three responses (often, sometimes, and rarely/never). “Often” means > 50% of the time and “sometimes” means < 50%.

B6. How frequently does your child do the following activities on synthetic fields/natural grass fields at this facility each season?

	Dive on ground		Fall on ground		Sit on turf		Eat snacks		Drink
Spring
Summer
2
Fall
Winter

Inhalation Exposure-Related Questions

B7. When using synthetic fields/natural grass fields at this facility:

What % of the time is your child highly active, for example, running?

What % of the time is your child moderately active, for example, jogging?

What % of the time does your child have low activity, for example, walking?

What % of the time is your child resting, for example, sitting or standing?

Dermal and Non-Dietary Ingestion Exposure-Related Questions

For the following questions, please use one of the four responses (every time, often, sometimes, or rarely/never):

B8. When using synthetic turf fields/natural grass fields at this facility:

	Every Time		Often	Some times	Rarely / Never
How often does your child chew gum?		3	2	1	0
How often does your child use a mouth guard?		3	2	1	0
How often does your child eat?		3	2	1	0
How often does your child drink?		3	2	1	0
How often does your child play in the rain?		3	2	1	0
How often does your child wipe their hands with a hand wipe before eating?		3	2	1	0
How often does your child sweat heavily?		3	2	1	0
How often does your child touch the turf (with their hand)?		3	2	1	0
How often does your child touch the turf with their body excluding hands?		3	2	1	0
How often does your child sit on turf with bare skin wearing shorts?		3	2	1	0
How often is your child barefooted on the turf?		3	2	1	0
How often does your child play with the turf materials or rubber granules? (This question will not be populated for natural grass field users)		3	2	1	0
How often does your child touch their mouth with their hands or fingers?		3	2	1	0
How often does your child place non-food objects in their mouth every time like toothpicks, or pens or use their mouth to hold an object? If rarely/never, skip next.		3	2	1	0
What type of object does your child most often places in their mouth while at this facility?
How often does your child get cuts or abrasions from contact with the turf? If rarely/never, skip next.		3	2	1	0
What is the body part that usually has the most cuts or abrasions: knee, elbow, hand, thigh, shin, or other?

B9. What clothing does your child typically wear in this facility during each season (check all that apply)?

Spring Summer Fall Winter

Shorts

Short-sleeve shirt

Long pants

Long-sleeve shirt

Gloves

Socks

Helmet

Hat

Pads

Tire Crumb Take-Home Questions

For the following questions, please use one of the four responses (every time, often, sometimes, or rarely/never):

B10. After using this facility:

How often do you notice tire crumbs, dirt, or debris

	Every Time		Often	Sometimes	Rarely/Never
on your child‘s body?	3		2	1	0
in your car?	3		2	1	0
in your home?	3		2	1	0
In your laundry room/mudroom?	3		2	1	0
in living room?	3		2	1	0
in your child’s bedroom?	3		2	1	0
in your bathroom(s) your child uses?	3		2	1	0

Post-Use Hygiene Practices Questions

For the following questions, please use one of the four responses (every time, often, sometimes, or rarely/never):

B11. After using this facility:

	Every Time	Often	Sometimes	Rarely/Never
How often does your child shower and change clothes immediately after engaging in activities on the synthetic turf at this facility?	3	2	1	0
How often does your child’s shoes/equipment get wiped or removed before entering your home?	3	2	1	0

For the following questions, please use one of the six responses (never, once a month, 2 to 3 times a month, once a week, 2-3 times a week, or four or more times a week).

B12. At other locations:

	Never		Once a month		2 to 3 times a month		Once a week		2 to 3 times a week		4 or more times a week
How often has your child played on any other synthetic turf fields/natural grass fields during the past year?		0		1		2		3		4	5
How often has your child played on any synthetic turf fields/natural grass fields in the last five years?		0		1		2		3		4	5
How often has your child played on any natural grass fields/synthetic turf fields during the past year?		0		1		2		3		4	5
How often has your child played on any natural grass fields/synthetic turf fields in the last five years?		0		1		2		3		4	5
How often has your child played on playgrounds with rubber mulch, mats or synthetic turf during the past year?		0		1		2		3		4	5
How often has your child played on playgrounds with rubber mulch, mats or synthetic turf during in the last five years?		0		1		2		3		4	5

General Hygiene Questions

B13. How many times in general does your child wash their hands per day?

B14. How many times in general does your child bathe or shower per week?

Exposure-related Questions

C1. How does your child get to school on a typical day? Car School bus

Bike Walk Other

C2. How much time does it take your child to get to school on a typical day? _______________

C3. How did your child get to the practice field today? Car School bus

Bike Walk Other

C4. How much time did it take your child to get to practice today? ___________________

C5. Did your child eat grilled, barbequed, smoked, or deep fried food during the last 24 hours?

Yes No

C5a. If yes, please describe which of the food descirbed above that your child ate and when? (Hint: Barbequed chicken, grilled steak)

General Demographic Questions

D1. How old is your child?

D2. Is your child male or female? Male Female Refused

D3. Do you consider your child to be Hispanic or Latino? Yes No Refused

D4. Which of the following categories best describes your child’s race? (select one or more)

	Native American Indian or Alaska Native		Black or African American		White		Don’t know
	Asian		Native Hawaiian or Other Pacific Islander		Refused

D5. How tall is your child? (ft) (in)

D6. How much does your child weigh? (lbs)

D7. What is your child’s current grade in school?

	2nd		6th		Other
	3rd		7th		Refused
	4th		8th
	5th		9th

Specify other grade

That concludes the survey. Thank you for your time. I know that your time is valuable.

If you have any questions or concerns, please, refer to the contact sheet for information on who to contact.