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Form Approved

OMB No. 0923-0062

Exp. Date 10/31/2021

Exposure Measurement Form

Appendix N6

Supplemental Exposure Measurement Form

Study ID Number _______________________

Sample Collection Date _______________________

Collector ID _______________________

Field ID _______________________

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).

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:

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 Type	application/vnd.openxmlformats-officedocument.wordprocessingml.document
Author	CDC User
File Modified	0000-00-00
File Created	2021-08-02