Synthetic Turf Field Facility Participation Agreement 02AUG2016

Attachment 4g. Synthetic Turf Field Facility Participation Agreement

(Flesch-Kincaid Reading Level: Grade 9.5)

PARTICIPATION AGREEMENT

United States Environmental Protection Agency and the Agency for Toxic Substances and Disease Registry

Collections Related to Synthetic Turf Fields with Crumb Rubber Infill

Overview

The Agency for Toxic Substances and Disease Registry (ATSDR) and the United States Environmental Protection Agency (USEPA) invite you to be in a project to measure the amount of chemicals in crumb rubber infill used in synthetic turf fields and to look at field conditions that might affect the chemicals in the crumb rubber infill.

You are being asked to participate in this project. Your participation is voluntary. After you read about the project and before you decide to participate, please ask questions if there is anything that you do not understand.

What is the purpose of this project?

The purpose is to see what chemicals and microbes are present in crumb rubber infill used in synthetic turf fields. To help us understand the results, we also want to know about standard operating procedures for the synthetic turf fields, such as rubber redistribution.

We will use the results of this project to better understand the most relevant chemicals, exposures to those chemicals, and toxicity information available for those chemicals found in crumb rubber infill used in synthetic turf fields.

Why are you being asked to be in this project?

You were chosen to participate in this research project because your facility was identified as having synthetic turf fields with crumb rubber infill, and you completed a survey that indicated you were eligible and willing to participate. ATSDR and EPA hope to get 10 facilities in each of the 4 US regions for a total of 40 facilities.

Public reporting burden of this collection of information is estimated to average 5 minutes per response for total participation, 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-XXXX).

Public reporting burden of this collection of information is estimated to average 5 minutes per response for total participation, 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-XXXX).

What are we asking you to do?

• We will ask you a few questions about your responsibilities then we will interview you and ask questions about the facility. The interview will take 30 minutes. During the interview we will ask questions about the facility use, the types of synthetic turf fields at your/this facility, and the standard operating procedures for the synthetic turf fields at your/this facility.

• You will be asked to provide permission for us to collect samples of the crumb rubber infill in synthetic turf fields.

• USEPA and ATSDR are also conducting a sub-study looking at exposure measurements in people who play on synthetic turf fields. We will also ask you if you are willing to allow us to recruit people who play on the synthetic turf fields at your facility. These people who use the fields in your facility would be asked to complete a questionnaire about their activities on synthetic turf fields. Some of these people also would be asked to participate in an exposure measurement study. If these people agree, we would return and make additional measurements while they are using the facility, including air samples, surface wipe samples, and dust samples from the field they use.

How long will this take?

It will take about 30 minutes to complete the facility manager interview.

It will take about 3 hours for us to collect crumb rubber samples from the field.

What will the field samples be tested for?

We will collect tire crumb rubber samples from seven different locations on one field. The total amount collected will be about six pounds. We will look for chemicals and evidence of microbes in the crumb rubber infill, including

• Metals

• Volatile Organic Compounds

• Semi-Volatile Organic Compounds

• Microbial activity

We will also characterize particle sizes for the collected material.

We would like your permission for us to store the leftover samples to possibly test for other chemicals in the future.

Are there any risks or discomforts to you if you decide to be in this project?

There are no risks from the field collection or the questionnaire. The facility owners will not incur any costs for the laboratory tests performed by the federal government.

Are there any benefits to you from being in this project? EPA and ATSDR will give facility users/managers access to the data collected from their facility.

Who will see the information you give the researchers?

All information about you (including your name and address, this form, and your interview answers) will be secure. We keep track of your information using a code number rather than your name. We will keep paper records in locked files and electronic records are stored on password protected computers at the USEPA. Only staff working on the project will be allowed to look at the paper and electronic records. Federal policy requires making the data we collect available to the public, but we will not include your name or other identifying information in public release. However, identifying information may be released in the event of a Freedom of Information Act request.

What is the cost to you?

The only cost to you for being in our project is your time and effort to take part. We will be collecting about six pounds of crumb rubber; however, the collection will occur in seven locations on the field (less than one pound per location).

What are your choices about participating?

Your participation in this project is voluntary. You are free to be a part of it or not. You can refuse to answer any interview questions. You can choose to leave at any time, even after you have signed the participation agreement form.

Who should you contact if you have questions later on?

If you have any question about the project or wish to drop out, please contact:

Elizabeth Irvin-Barnwell, CDC/ATSDR Project Officer

Jcx0@cdc.gov

770-488-3684

What should you do after reading this information?

If you do not understand what we are asking you to do, please ask questions. After all your questions have been answered to your satisfaction and if you want to be in this project, please sign the consent form on the next page.

United States Environmental Protection Agency and the Agency for Toxic Substances and Disease Registry

Collections Related to Synthetic Turf Fields with Crumb Rubber Infill

Access Agreement and Consent to Participate

I have read the above information about the project “Collections Related to Synthetic Turf Fields with Crumb Rubber Infill.” I have been allowed to ask questions and I had all my questions answered.

By signing below, I agree to take part in the interview and to allow USEPA and ATSDR to collect crumb rubber samples from my synthetic turf fields.

_______________________________________________

Participant’s name (Print)

_______________________________________________

Participant's signature / Date

_____________________________________________________________

Organization/Facility Name Participant Position/Title

By signing below, I give USEPA and ATSDR permission to store my leftover field samples to test for other contaminants at a later date.

_______________________________________________

Participant’s name (Print)

_______________________________________________

Participant's signature / Date

By signing below, I am indicating I would like to receive a copy of the laboratory results from the crumb rubber samples collected from my facility.

_______________________________________________

Participant’s name (Print)

_______________________________________________

Participant's signature / Date

______________________________________________________________________________

Mailing Address for results

By signing below, I will volunteer information to USEPA and ATSDR on individuals who use the synthetic turf field facilities. This information can include individual names of field users and/or dates and times of group activities (i.e. intramural sports activities). I also agree to hand out information sheets to individuals who use the synthetic turf field facilities.

_______________________________________________

Participant’s name (Print)

_______________________________________________

Participant's signature / Date

By signing below, I give USEPA and ATSDR permission to recruit players at my facility, and if they participate, to allow USEPA and ATSDR to collect air, wipe, and dust samples.

_______________________________________________

Participant’s name (Print)

_______________________________________________

Participant's signature / Date