0923-0062 Exposure Measurement Form

Supplemental Measurements for Exploratory Research regarding Exposure during Activities Conducted on Synthetic Turf Fields with Tire Crumb Rubber Infill

P_AppxN6_ExpMeasurementForm 20210222 cln

OMB: 0923-0062

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Form Approved

OMB No. 0923-0062

Exp. Date 10/31/2021



Exposure Measurement Form

Appendix N6


Supplemental Exposure Measurement Form

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Study ID Number _______________________

Sample Collection Date _______________________

Collector ID _______________________

Field ID _______________________


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ATSDR estimates the average public reporting burden for this collection of information as 10 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).





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Study ID Number _______________________

NOTE: Use one form for each participant if multiple participants are part of a sampling event



For natural grass field user participants:

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Shape6 Have you played on a synthetic turf field in the past 24 hours? Yes No

If yes, participant is not eligible to participate at this time.

If no, participant is eligible to participate and investigator will proceed with data collection.



Task


Completion

Comments

Temperature below 100.4˚F/no self-reported symptoms

Yes

No


Consent/Parental Permission/Assent Form

Yes

No


Urine Samples


Sample Type


Sample Collected

Urine volume

Time of collection

Pre-Activity

Yes No



Post-Activity

Yes No





What time of the day was your/your child’s most recent void? ________________


File Typeapplication/vnd.openxmlformats-officedocument.wordprocessingml.document
AuthorCDC User
File Modified0000-00-00
File Created2021-08-02

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