Form 0920-19GW Eligibility Screener

Form Approved

OMB No. 0923-0062

Exp. Date 10/31/2021

Field User Eligibility Screening Form

Appendix N2

The purpose of the exposure measurement study is to determine how people might be exposed to chemicals in the tire crumbs on synthetic turf fields. We are including natural grass field users for comparison. We need synthetic turf field users and natural grass field users to:

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

2. Provide a urine sample before and after an athletic or training activity on the field.

ATSDR would like to recruit at least 200 people who engage in physical activities on synthetic turf fields with tire crumb rubber infill or on natural grass fields 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 field surfaces. ATSDR would also like to perform chemical measurements on urines from these individuals.

Please be assured that ATSDR will take all necessary steps to protect members of your community from COVID-19. This study will be conducted following all state, local, and CDC guidelines in place at the time the study is conducted. ATSDR team members will be monitored twice daily for fever and any COVID-19-related symptoms and will wear masks and gloves to ensure the protection of participants. Similarly, participants will be monitored for fever and COVID-19-related symptoms prior to their entry into the testing facility and will be asked to wear a face covering or mask. If you do not have a mask, one will be provided to you.

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.

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 (0923-0062).

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. Are you a smoker or do you (or your child) live in a household with a smoker? ………………

If yes, respondent is not eligible to participate.

For Natural Grass Field Users:

5. Have you (has your child) played on synthetic turf fields with tire crumb rubber infill during the last 24 hours? …………………………………………

If yes, respondent is not eligible to participate.

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

6. Would you (would your child) be willing to complete a short survey to collect information about your (his/her) time and activities that might affect exposures to chemicals associated with synthetic turf fields?.................................................................. 

7. ATSDR would like to check for select chemicals that people might be exposed to from synthetic turf fields with crumb rubber infill or from natural grass fields. For this purpose, would you (would your child) be willing to give two urine samples, one before and one after your (his/her) time on the field?

Yes….. 

No…....

If potential participant will not be practicing on a synthetic turf field or natural grass field within the sample collection time frame (e.g. next two weeks)

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

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.