Consent/Assent Form

Att3d_ConsentAssentForms.docx

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

Consent/Assent Form

OMB: 0923-0062

⚠️ Notice: This form may be outdated. More recent filings and information on OMB 0923-0062 can be found here:

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Exposure Measurement Study Consent, Assent, Permission Forms

OMB Attachment 3d

Agency for Toxic Substances and Disease Registry

Exposure Measurements during Activities Conducted on

Synthetic Turf Fields with Tire Crumb Rubber Infill

CONSENT TO PARTICIPATE IN A RESEARCH STUDY

Overview

The Agency for Toxic Substances and Disease Registry (ATSDR) invites you, as an adult aged 18 or older (or the legal age in your state), to be in a research study about personal exposures either from synthetic turf fields or from natural grass fields. Your participation is voluntary. We invite you to read or hear about the study. Before you decide to take part, please ask questions if there is anything that you do not understand.

What is the purpose of this study?

The purpose is to see how people might be exposed to chemicals in crumb rubber infill in synthetic turf. Crumb rubber is the black material used as cushioning in synthetic turf fields. The crumb rubber is most often made from recycled tires. For comparison, we will also be recruiting some people who play on natural grass fields. We want to ask some questions about your activities on synthetic turf fields or natural grass fields. We will also collect urine samples from you. This information will help us see if people might be exposed to chemicals from playing on synthetic turf fields. We will use the results of this study to guide public health actions.

Why are you being asked to be in this study?

You were chosen to take part in this study because you work out on synthetic turf fields or on natural grass fields. We want to talk to people like you who take part in recreation, training, or organized sports on these fields.

ATSDR hopes to enroll at least 200 people to answer some questions and to provide urine samples so we can look what chemicals you are exposed to while playing on the field. In total, participants will spend about 50 minutes in this research study.

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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 yourself in an interview. We will ask questions about your activities on synthetic turf or natural grass fields. We want to know about the types of your activities, how often you play on the fields, and how long you have been playing on the fields.
You will be asked to provide 50-100 ml (about ½ cup) of urine in a cup both before your practice and after your practice. You will do this in private in a restroom.

We will not be collecting any personal information (e.g. names, address, etc.), and you will not receive a copy of your test results.

How long will this take?

It will take about 30 minutes to complete the interview. It will take about ten minutes to collect each of the urine samples.

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

We don’t think these questions are sensitive. But the interview may be stressful if you have to recall events that are upsetting. You are free to skip any question for any reason. There are no medical risks from providing urine.

Are there any benefits to you from being in this study?

There will be no direct benefits to you from being in this study.

Who will see the information you give the researchers?

All information that you provide will be secure. We will track your information using a study ID number. We do not plan to link your study ID number with your identity. We will keep paper records in locked files. Electronic records will be stored on password protected computers at ATSDR. Only trained study staff will be allowed to look at your records. Federal policy requires making the data we collect available to the public.

What will happen to my urine samples?

Your urine samples will be shipped to and stored at the Centers for Disease Control and Prevention (CDC) laboratory in Atlanta, GA.

Your urine samples will be analyzed to look for some chemicals that might be found in crumb rubber infill or in the natural grass field. Afterwards, the samples will be stored for the indefinite future. This is in case we get more information in the future about what chemicals to look for or in the case that new methods are developed to test for chemicals found in crumb rubber infill.

We will not analyze these samples for DNA, drugs, tobacco, or health conditions.

Your potential future urine results may be linked to the questionnaire data that you are asked to provide. Your samples will be labeled with a study ID number only and will not be shared with researchers outside of CDC/ATSDR.

What is the cost to you and what compensation will you get?

The only cost for being in our study is your time and effort to take part. We will give you a $25 gift card as a “thank you” when you complete the interview. You can use the gift card at most stores or for online shopping.

People who also provide urine samples will get additional gift cards ($10 pre-activity and $15 post-activity).

What are your choices about participating?

Your participation in this study is voluntary. You are free to be a part of it or not. You can refuse to give a urine sample. You can choose to leave at any time prior to final sample collection even after you have agreed to participate in the study.

Who should you contact if you have questions later on?

If you have any questions about the study, please contact:

Kelsey Benson

Kbenson@cdc.gov

770-488-0684

For questions about your rights as a research subject, please contact:

Centers for Disease Control and Prevention (CDC)/ATSDR Human Research Protection Helpline

800-584-8814

Please leave a message and say you are calling about protocol 6881.

If you feel you have been harmed by this study please contact:

Dr. Elizabeth Irvin-Barnwell

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 study, please let the study interviewer know. As a way to protect your privacy, we will not ask you for your signature. You will be given a copy of this form for your records.

Agency for Toxic Substances and Disease Registry

Exposure Characterization and Measurements during Activities Conducted on Synthetic Turf Fields with Tire Crumb Rubber Infill

CONSENT TO PARTICIPATE IN A RESEARCH STUDY

I have read the above information, or it has been read to me, about the study titled Exposure Characterization and Measurements during Activities Conducted on Synthetic Turf Fields with Tire Crumb Rubber Infill. I have been allowed to ask questions and I had all my questions answered.

I agree to take part in the research and the interview. ☐

I agree to provide urine samples. I give ATSDR permission to store my urine to do the tests later. I understand that ATSDR will not send my test results to me. ☐

Shape3

Participant Label

PARENTAL/GUARDIAN PERMISSION FOR

ADOLESCENT PARTICIPATION IN A RESEARCH STUDY

Exposure Characterization and Measurements during Activities Conducted on Synthetic Turf Fields with Tire Crumb Rubber Infill

Overview

The Agency for Toxic Substances and Disease Registry (ATSDR) invites you to give permission for your adolescent, aged 13 to 17 years (or up to the legal age in your state), to be in a research study about personal exposures either from synthetic turf fields or from natural grass fields. Your adolescent’s participation is voluntary. We invite you both to read or hear about the study. Before you decide to allow your adolescent to take part, please ask questions if there is anything that you do not understand.

What is the purpose of this study?

The purpose is to see how people might be exposed to chemicals in crumb rubber infill in synthetic turf. Crumb rubber is the black material used as cushioning in synthetic turf fields. The crumb rubber is most often made from recycled tires. For comparison, we will also be recruiting some people who play on natural grass fields. We want to ask some questions about your adolescent’s activities on synthetic turf fields or natural grass fields. We will also collect urine samples from your adolescent. This information will help us see if people might be exposed to chemicals from playing on synthetic turf fields. We will use the results of this study to guide public health actions.

Why is your adolescent being asked to be in this study?

Your adolescent was chosen to take part in this study because he/she works out on synthetic turf fields or natural grass fields. We want to talk to people like him/her who take part in recreation, training, or organized sports on these fields.

ATSDR hopes to enroll at least 200 people to answer some questions and to provide urine samples so we can look what chemicals your adolescent is exposed to while playing on the field. In total, participants will spend about 50 minutes in this research study.

Shape4 Shape5

What are we asking your adolescent to do?

We will ask him/her a few questions in an interview. We will ask questions about his/her activities on the fields. We want to know about the types of his/her activities, how often he/she plays on the fields, and how long he/she has been playing on the fields.
He/she will be asked to provide 50-100 ml (about ½ cup) of urine in a cup both before his/her practice and after his/her practice. He/she will do this in private in a restroom.

We will not be collecting any personal information (e.g. names, address, etc.), and you will not receive a copy of your adolescent’s test results.

How long will this take?

It will take about 30 minutes to complete the interview. It will take about ten minutes to collect each of the urine samples.

Are there any risks or discomforts to your adolescent if he/she decides to be in this study?

We don’t think these questions are sensitive. But the interview may be stressful if he/she has to recall events that are upsetting. He/she is free to skip any question for any reason. There are no medical risks from providing urine.

Are there any benefits to your adolescent from being in this study?

There will be no direct benefits to him/her from being in this study.

Who will see the information your adolescent gives the researchers?

All information about your adolescent provides will be secure. We will track his/her information using a study ID number. We do not plan to link your adolescent’s study ID number with his/her identity. We will keep paper records in locked files. Electronic records will be stored on password protected computers at ATSDR. Only trained study staff will be allowed to look at his/her records. Federal policy requires making the data we collect available to the public.

What will happen to his/her urine samples?

His/her urine samples will be shipped to and stored at the Centers for Disease Control and Prevention (CDC) laboratory in Atlanta, GA. Your adolescent’s urine samples will be analyzed to look for some chemicals that might be found in crumb rubber infill or natural grass fields. Afterwards, the samples will be stored for the indefinite future. This is in case we get more information in the future about what chemicals to look for or in the case that new methods are developed to test for chemicals found in crumb rubber infill.

We will not analyze these samples for DNA, drugs, tobacco, or health conditions.

Your adolescent’s potential future urine results may be linked to the study data that he/she is asked to provide today.

His/her samples will be labeled with a study ID number only and will not be shared with researchers outside of CDC/ATSDR.

What is the cost to your adolescent and what compensation will he/she get?

The only cost for being in our study is your adolescent’s time and effort to take part. We will give your adolescent a $25 gift card as a “thank you” when he/she completes the interview. Your adolescent can use the gift card at most stores or for online shopping.

People who also provide urine samples will get additional gift cards ($10 pre-activity and $15 post-activity).

What are your adolescent’s choices about participating?

Your adolescent’s participation in this study is voluntary. He/she is free to be a part of it or not. He/she can refuse to give a urine sample. He/she can choose to leave at any time prior to final sample collection even after he/she has agreed to participate in the study.

Who should you and your adolescent contact there are questions later on?

If you or your adolescent have any questions about the study, please contact:

Kelsey Benson

Kbenson@cdc.gov

770-488-0684

For questions about your adolescent’s rights as a research subject, please contact:

Centers for Disease Control and Prevention (CDC)/ATSDR Human Research Protection Helpline

800-584-8814

Please leave a message and say you are calling about protocol 6881.

If you feel your adolescent has been harmed by this study please contact:

Dr. Elizabeth Irvin-Barnwell

Jcx0@cdc.gov

770-488-3684

What should you do after reading this information?

If you or your adolescent do not understand what we are asking him/her to do, please ask questions. After all your questions have been answered to your satisfaction and if you permit your adolescent to be in this study, please let the study interviewer know. As a way to protect your privacy, we will not ask you or your adolescent for signatures. You will be given a copy of these forms for your records.

Agency for Toxic Substances and Disease Registry

Exposure Characterization and Measurements during Activities Conducted on Synthetic Turf Fields with Tire Crumb Rubber Infill

PARENTAL/GUARDIAN PERMISSION FOR ADOLESCENT PARTICIPATION IN A RESEARCH STUDY

I permit my adolescent to take part in the research and the interview. ☐

I permit my adolescent to provide urine samples. I give ATSDR permission to store my adolescent’s urine to do the tests later. I understand that ATSDR will not send my adolescent’s test results to me. ☐

Shape6

Participant Label

Agency for Toxic Substances and Disease Registry

Exposure Characterization and Measurements during Activities Conducted on Synthetic Turf Fields with Tire Crumb Rubber Infill

ADOLESCENT ASSENT TO BE IN A RESEARCH STUDY

We are doing a study to learn about how people use playing fields with crumb rubber and to see how people might be exposed to chemicals in crumb rubber infill in synthetic turf. Crumb rubber is the black stuff that makes the fields soft to play on. It is usually made from recycled tires. We also want to learn if people are exposed to chemicals from the crumb rubber. We are asking adolescents, 13 to 17 years of age, to participate in this study. For comparison, we will also be recruiting some people who play on natural grass fields. You were selected to take part in this study because you play on synthetic turf with crumb rubber or on natural grass fields.

If you agree to be in our study, we are going to ask you some questions about how you play or practice on the fields. For example, we want to know how often you fall or slide on the ground.

You can ask questions about this study at any time. It should take about 30 minutes to finish the interview. If you decide at any time not to finish, you can ask us to stop.

The questions we will ask are about how you play or practice on the fields. There are not right or wrong answers because this is not a test.

We will collect two urine samples, one before you begin your activity on the field and one after you finish your activity on the field. We will ask you to collect your urine in a cup we will give you. It should take you 10 minutes for each sample to do this.

Other Information

There are no risks from giving urine.

Your mom/dad has said it is ok for you to be in the study but it is up to you if you want to take part. You can decide whether or not to take part in this study. You can ask questions about this study at any time. If you decide at any time not to finish, you can ask us to stop.

If You Have Questions

If you have any questions now, please ask us. If you have questions later, your parents/guardians have information about who to call.

I agree to take part in the research, including the interview and providing urine samples. ☐

Agency for Toxic Substances and Disease Registry

Exposure Characterization and Measurements during Activities Conducted on Synthetic Turf Fields with Tire Crumb Rubber Infill

PARENTAL/GUARDIAN PERMISSION FOR YOUTH PARTICIPATION IN A RESEARCH STUDY

Overview

The Agency for Toxic Substances and Disease Registry (ATSDR) invites you to give permission for your youth, aged 10 to 12 years, to be in a research study about personal exposure either from synthetic turf fields or from natural grass fields. Your youth’s participation is voluntary. We invite you both to read or hear about the study. Before you decide to allow your youth to take part, please ask questions if there is anything that you do not understand.

What is the purpose of this study?

The purpose is to see how people might be exposed to chemicals in crumb rubber infill in synthetic turf. Crumb rubber is the black material used as cushioning in synthetic turf fields. The crumb rubber is most often made from recycled tires. For comparison, we will also be recruiting some people who play on natural grass fields. We want to ask some questions about your youth’s activities on synthetic turf fields or natural grass fields. We will also collect urine samples from your youth. This information will help us see if people might be exposed to chemicals from playing on synthetic turf fields. We will use the results of this study to guide public health actions.

Why is your youth being asked to be in this study?

Your youth was chosen to take part in this study because he/she works out on synthetic turf fields or natural grass fields. We want to talk to people like him/her who take part in recreation, training, or organized sports on these fields.

ATSDR hopes to enroll at least 200 people to answer some questions and to provide urine samples so we can look what chemicals your youth is exposed to while playing on the field. In total, participants will spend about 50 minutes in this research study.

Shape7 Shape8

What are we asking your youth to do?

We will ask you a few questions about your youth in an interview. We will ask questions about his/her activities on synthetic turf fields or natural grass fields. We want to know about the types of his/her activities, how often he/she plays on the fields, and how long he/she has been playing on the fields.
He/she will be asked to provide 50-100 ml (about ½ cup) of urine in a cup both before his/her practice and after his/her practice. He/she will do this in private in a restroom.

We will not be collecting any personal information (e.g. names, address, etc.), and you will not receive a copy of your youth’s test results.

How long will this take?

It will take about 30 minutes to complete the interview. It will take about ten minutes to collect each of the urine samples.

Are there any risks or discomforts to your youth if he/she decides to be in this study?

Are there any benefits to your youth from being in this study?

There will be no direct benefits to him/her from being in this study.

Who will see the information your youth gives the researchers?

All information that you provide will be secure. We will track his/her information using a study ID number. We do not plan to link your youth’s study ID number with his/her identity. We will keep paper records in locked files. Electronic records will be stored on password protected computers at ATSDR. Only trained study staff will be allowed to look at his/her records. Federal policy requires making the data we collect available to the public.

What will happen to his/her urine samples?

His/her urine samples will be shipped to and stored at the Centers for Disease Control and Prevention (CDC) laboratory in Atlanta, GA. Your youth’s urine samples will be analyzed to look for some chemicals that might be found in crumb rubber infill or in the natural grass field. Afterwards, the samples will be stored for the indefinite future. This is in case we get more information in the future about what chemicals to look for or in the case that new methods are developed to test for chemicals found in crumb rubber infill.

We will not analyze these samples for DNA, drugs, tobacco, or health conditions.

Your youth’s potential future urine results may be linked to the study data that you are asked to provide today. His/her samples will be labeled with a study ID number only and will not be shared with researchers outside of CDC/ATSDR.

What is the cost to your youth and what compensation will he/she get?

The only cost for being in our study is your youth’s time and effort to take part. We will give your youth a $25 gift card as a “thank you” when he/she completes the interview. Your youth can use the gift card at most stores or for online shopping.

People who also provide urine samples will get additional gift cards ($10 pre-activity and $15 post-activity).

What are your youth’s choices about participating?

Your youth’s participation in this study is voluntary. He/she is free to be a part of it or not. He/she can refuse to give a urine sample. He/she can choose to leave at any time prior to final sample collection even after he/she has agreed to participate in the study.

Who should you and your youth contact there are questions later on?

If you or your youth have any questions about the study, please contact:

Kelsey Benson

Kbenson@cdc.gov

770-488-0684

For questions about your youth’s rights as a research subject, please contact:

Centers for Disease Control and Prevention (CDC)/ATSDR Human Research Protection Helpline

800-584-8814

Please leave a message and say you are calling about protocol 6881.

If you feel your youth has been harmed by this study please contact:

Dr. Elizabeth Irvin-Barnwell

Jcx0@cdc.gov

770-488-3684

What should you do after reading this information?

If you or your youth do not understand what we are asking him/her to do, please ask questions. After all your questions have been answered to your satisfaction and if you permit your youth to be in this study, please let the study interviewer know. As a way to protect your privacy, we will not ask you or your youth for signatures. You will be given a copy of these forms for your records.

Agency for Toxic Substances and Disease Registry

Exposure Characterization and Measurements during Activities Conducted on Synthetic Turf Fields with Tire Crumb Rubber Infill

PARENTAL/GUARDIAN PERMISSION FOR YOUTH PARTICIPATION IN A RESEARCH STUDY

I permit my youth to take part in the research and the interview. ☐

I permit my youth to provide urine samples. I give ATSDR permission to store my youth’s urine to do the tests later. I understand that ATSDR will not send my youth’s test results to me. ☐

Shape9

Participant Label

Agency for Toxic Substances and Disease Registry

Exposure Characterization and Measurements during Activities Conducted on Synthetic Turf Fields with Tire Crumb Rubber Infill

YOUTH ASSENT TO BE IN A RESEARCH STUDY

We are doing a study to learn about how people use playing fields with crumb rubber and to see how people might be exposed to chemicals in crumb rubber infill in synthetic turf. Crumb rubber is the black stuff that makes the fields soft to play on. It is usually made from recycled tires. We also want to learn if people are exposed to chemicals from the crumb rubber. For comparison, we will also be recruiting some people who play on natural grass fields. We want to ask some questions about your activities on synthetic turf fields or natural grass fields. We are asking you to help because we do not know very much about how kids your age play or practice on these fields.

If you agree to be in our study, we are going to ask your Mom/Dad/guardian some questions about how you play or practice on the fields. You can help with the answers. For example, we want to know how often you fall or slide on the ground.

We will ask are about how you play or practice on the fields. There are not right or wrong answers because this is not a test.

We will collect two urine samples, one before you begin practice and one after you finish. We will ask you to collect your urine in a cup we will give you. It should take you 10 minutes for each sample to do this. There are no risks from giving urine.

You and your Mom/Dad/guardian can ask questions about this study at any time. It should take about 30 minutes to finish the interview. If you both decide at any time not to finish, you can ask us to stop.

Your mom/dad has said it is ok for you to be in the study but it is up to you if you want to take part. Being in the study is up to you. No one will be upset if you don’t want to be in the study or if you change your mind later.

If You Have Questions

If you have any questions now, please ask us. If you have questions later, your parents/guardians have information about who to call.

I agree to take part in the research, including the interview and providing urine samples. ☐

Agency for Toxic Substances and Disease Registry

Exposure Characterization and Measurements during Activities Conducted on Synthetic Turf Fields with Tire Crumb Rubber Infill

PARENTAL/GUARDIAN PERMISSION FOR CHILD PARTICIPATION IN A RESEARCH STUDY

Overview

The Agency for Toxic Substances and Disease Registry (ATSDR) invites you to give permission for your child, aged 7 to 9 years, to be in a research study about personal exposure either from synthetic turf fields or from natural grass fields. Your child’s participation is voluntary. We invite you both to read or hear about the study. Before you decide to allow your child take part, please ask questions if there is anything that you do not understand.

What is the purpose of this study?

The purpose is to see how people might be exposed to chemicals in crumb rubber infill in synthetic turf. Crumb rubber is the black material used as cushioning in synthetic turf fields. The crumb rubber is most often made from recycled tires. For comparison, we will also be recruiting some people who play on natural grass fields. We want to ask some questions about your child’s activities on synthetic turf fields or on natural grass fields. We will also collect urine samples from your child. This information will help us see if people might be exposed to chemicals from playing on synthetic turf fields. We will use the results of this study to guide public health actions.

Why are your child being asked to be in this study?

Your child was chosen to take part in this study because he/she works out on synthetic turf fields or on natural grass fields. We want to talk to people like him/her who take part in recreation, training, or organized sports on these fields.

ATSDR hopes to enroll at least 200 people to answer some questions and to provide urine samples so we can look what chemicals your child is exposed to while playing on the field. In total, participants will spend about 50 minutes in this research study.

Shape10 Shape11

What are we asking your child to do?

We will ask you a few questions about your child in an interview. We will ask questions about his/her activities on synthetic turf fields or natural grass fields. We want to know about the types of his/her activities, how often he/she plays on the fields, and how long he/she has been playing on the fields.
He/she will be asked to provide 50-100 ml (about ½ cup) of urine in a cup both before his/her practice and after his/her practice. He/she will do this in private in a restroom.

You will not receive a copy of your child’s test results.

How long will this take?

It will take about 30 minutes to complete the interview. It will take about ten minutes to collect each of the urine samples.

Are there any risks or discomforts to your child if he/she decides to be in this study?

Are there any benefits to your child from being in this study?

There will be no direct benefits to him/her from being in this study.

Who will see the information your child gives the researchers?

All information that you provide will be secure. We will track his/her information using a study ID number rather than name. We do not plan to link your child’s study ID number with his/her identity. We will keep paper records in locked files. Electronic records will be stored on password protected computers at ATSDR. Only trained study staff will be allowed to look at his/her records. Federal policy requires making the data we collect available to the public.

What will happen to his/her urine samples?

His/her urine samples will be shipped to and stored at the Centers for Disease Control and Prevention (CDC) laboratory in Atlanta, GA. Your child’s urine samples will be analyzed to look for some chemicals that might be found in crumb rubber infill or in the natural grass field. Afterwards, the samples will be stored for the indefinite future. This is in case we get more information in the future about what chemicals to look for or in the case that new methods are developed to test for chemicals found in crumb rubber infill.

We will not analyze these samples for DNA, drugs, tobacco, or health conditions.

Your child’s potential future urine results may be linked to the study data that you are asked to provide today. His/her samples will be labeled with a study ID number only and will not be shared with researchers outside of CDC/ATSDR.

What is the cost to your child and what compensation will he/she get?

The only cost for being in our study is your child’s time and effort to take part. We will give your child a $25 gift card as a “thank you” when he/she completes the interview. Your child can use the gift card at most stores or for online shopping.

People who also provide urine samples will get additional gift cards ($10 pre-activity and $15 post-activity).

What are your child’s choices about participating?

Your child’s participation in this study is voluntary. He/she is free to be a part of it or not. He/she can refuse to give a urine sample. He/she can choose to leave at any time prior to final sample collection even after he/she has agreed to participate in the study.

Who should you and your child contact there are questions later on?

If you or your child have any questions about the study, please contact:

Kelsey Benson

Kbenson@cdc.gov

770-488-0684

For questions about your child’s rights as a research subject, please contact:

Centers for Disease Control and Prevention (CDC)/ATSDR Human Research Protection Helpline

800-584-8814

Please leave a message and say you are calling about protocol 6881.

If you feel your child has been harmed by this study please contact:

Dr. Elizabeth Irvin-Barnwell

Jcx0@cdc.gov

770-488-3684

What should you do after reading this information?

If you or your child do not understand what we are asking him/her to do, please ask questions. After all your questions have been answered to your satisfaction and if you permit your child to be in this study, please let the study interviewer know. As a way to protect your privacy, we will not ask you or your child for signatures. You will be given a copy of these forms for your records.

Agency for Toxic Substances and Disease Registry

Exposure Characterization and Measurements during Activities Conducted on Synthetic Turf Fields with Tire Crumb Rubber Infill

PARENTAL/GUARDIAN PERMISSION FOR CHILD PARTICIPATION IN A RESEARCH STUDY

I permit my child to take part in the research and the interview. ☐

I permit my child to provide urine samples. I give ATSDR permission to store my child’s urine to do the tests later. I understand that ATSDR will not send my child’s test results to me. ☐

Shape12

Participant Label

Agency for Toxic Substances and Disease Registry

Exposure Characterization and Measurements during Activities Conducted on Synthetic Turf Fields with Tire Crumb Rubber Infill

Child Assent Form

We are doing a study to learn about how people use playing fields with crumb rubber. Crumb rubber is the black stuff that makes the fields soft to play on. It is usually made from recycled tires. We also want to learn if people are exposed to chemicals from the crumb rubber. For comparison, we will also be recruiting some people who play on natural grass fields. We are asking kids ages 7-9 to participate in this study. You were picked because you play on fields with crumb rubber or on grass fields.

If you decide to be in the study, we are going to ask your Mom or Dad some questions about how you play on the fields. You can help with the answers. For example, we want to know how often you fall or slide on the ground.

We will ask you to pee in a cup two times, once before you play and once after you play. It should take you ten minutes each time to do this.

Other Information

Peeing in a cup might be a bit weird but it can’t hurt you. You will do this in private in the restroom.

Your mom/dad has said it is ok for you to be in the study, but it is up to you if you want to take part. You can ask us to stop at any time if you don’t want to finish.

If You Have Questions

If you have any questions now, please ask us. If you have questions later, your Mom or Dad will know who to call.

I agree to take part in the research, including the interview and providing urine samples. ☐

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