Adult/Adolescent Questionnaire

Form Approved

OMB No. 0923-XXXX

Exp. Date xx/xx/201x

Attachment 4d. Adult and Adolescent Questionnaire

Interviewer: I would like to ask you some questions about activities that may affect your exposures to, and contact with synthetic turf fields that contain crumb rubber materials.

Field Contact Frequency and Duration Questions

Interviewer: I have several questions about the time you spend on synthetic turf fields at this facility.

	(years)
	(months)

B1. How long have you been coming to this facility?

B2. Specifically on the synthetic fields at this facility, what sports, physical education classes, or other activities have you actively participated in by season (specify) over the past year?

Season		Sport		Specify Other

ATSDR estimates the average public reporting burden for this collection of information as 30 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-XXXX).

B3. Over the past year, how many days per week by season have you typically spent on the synthetic fields at this facility?

Spring		(days per week)
Summer		(days per week)
Fall		(days per week)
Winter		(days per week)

B4. Over the past year, how many hours per day by season have you typically spent on the synthetic fields at this facility?

Spring		(hours per day)
Summer		(hours per day)
Fall		(hours per day)
Winter		(hours per day)

B5. Over the past year, what was the longest period of time that you spent on the synthetic fields at this facility during a single day?

(number of hours)

Contact Types and Scenarios per Each Type of Field Use

Interviewer: I have several questions about the kinds of activities that you take part in specifically on synthetic turf fields installed at this facility.

For the following question, please use one of the three responses (often, sometimes, and rarely/never). “Often” means > 50% of the time and “sometimes” means < 50%.

B6. How frequently do you do the following activities while on synthetic fields at this facility each season?

	Dive on ground		Fall on ground		Sit on turf		Eat snacks		Drink
Spring
Summer
2
Fall
Winter

Inhalation Exposure-Related Questions

B7. When using synthetic fields at this facility:

What % of your time are you highly active, for example, running?

What % of your time are you moderately active, for example, jogging?

What % of the time do you have low activity, for example, walking?

What % of the time are you resting, for example, sitting or standing?

Dermal and Non-dietary Ingestion Exposure-related Questions

For the following questions, please use one of the four responses (every time, often, sometimes, or rarely/never):

	Every Time		Often	Some times	Rarely /Never
How often do you chew gum?		3	2	1	0
How often do you use a mouth guard?		3	2	1	0
How often do you eat?		3	2	1	0
How often do you drink?		3	2	1	0
How often do you play in the rain?		3	2	1	0
How often do you wipe your hands with a hand wipe before eating?		3	2	1	0
How often do you sweat heavily?		3	2	1	0
How often do you touch the turf with your hand?		3	2	1	0
How often do you touch the turf with your other body parts excluding hands?		3	2	1	0
How often do you sit on the turf with bare skin wearing shorts?		3	2	1	0
How often are you barefooted on the turf?		3	2	1	0
How often do you play with the turf materials or rubber granules?		3	2	1	0
How often do you touch your mouth with your hands or fingers?		3	2	1	0
How often do you place non-food objects in your mouth like toothpicks, or pens or use your mouth to hold an object? If rarely/never, skip next.		3	2	1	0
What type of object do you most often place in your mouth while at this facility?
How often to you get cuts or abrasions from contact with the turf? If rarely/never, skip next.		3	2	1	0
What is the body part that usually has the most cuts or abrasions: knee, elbow, hand, thigh, shin, or other?

B8. When using synthetic turf fields at this facility:

B9. What clothing do you typically wear in this facility during each season (check all that apply)?

Spring Summer Fall Winter

Shorts

Short-sleeve shirt

Long pants

Long-sleeve shirt

Gloves

Socks

Helmet

Hat

Pads

Tire Crumb Take-Home Questions

For the following questions, please use one of the four responses (every time, often, sometimes, or rarely/never):

B10. After using this facility:

How often do you notice tire crumbs, dirt, or debris

	Every Time		Often	Sometimes	Rarely/Never
on your body?	3		2	1	0
in your car?	3		2	1	0
in your home?	3		2	1	0
In your laundry room/mudroom?	3		2	1	0
In your living room?	3		2	1	0
In your bedroom?	3		2	1	0
In your bathroom(s)?	3		2	1	0

Post-Use Hygiene Practices Questions

For the following questions, please use one of the four responses (every time, often, sometimes, or rarely/never):

B11. After using this facility:

	Every Time	Often	Sometimes	Rarely/Never
How often do you take shower and change clothes immediately after engaging in activities on the synthetic turf at this facility?	3	2	1	0
How often do you wipe or remove shoes/equipment before entering your home?	3	2	1	0

For the following questions, please use one of the six responses (never, once a month, 2 to 3 times a month, once a week, 2-3 times a week, or four or more times a week).

B12. At other locations:

	Never	Once a month	2 to 3 times a month	Once a week	2 to 3 times a week	4 or more times a week
How often have you played on any other synthetic turf fields during the past year?	0	1	2	3	4	5
How often have you played on any synthetic turf fields in the last five years?	0	1	2	3	4	5
How often have you played on any natural grass fields during the past year?	0	1	2	3	4	5
How often have you played on any natural grass turf fields in the last five years?	0	1	2	3	4	5
How often have you played on playgrounds with rubber mulch, mats or synthetic turf during the past year?	0	1	2	3	4	5
How often have you played on playgrounds with rubber mulch, mats or synthetic turf during in the last five years?	0	1	2	3	4	5

General Hygiene Questions

B13. How many times in general do you wash hands per day?

B14. How many times in general do you bathe or shower per week?

General Demographic Questions

D1. How old are you?

D2. Are you male or female? Male Female Refused

D3. Do you consider yourself to be Hispanic or Latino? Yes No Refused

D4. Which of the following categories best describes your race? (select one or more)

	Native American Indian or Alaska Native		Black or African American		White		Don’t know
	Asian		Native Hawaiian or Other Pacific Islander		Refused

D5. How tall are you? (ft) (in)

D6. How much do you weigh? (lbs)

D7. Are you still in school? yes no

If so, what is your current grade in school?

	7th		8th		9th
	10th		11th		12th
	Technical School		College		Graduate School
	Other		Refused

Specify Other Grade

D8. If No, what is your highest education level?

	11th or less		High School Graduate/ GED		Post High School Training
	Some College		College Graduate School		Post-graduate
	Other				Refused

D9. What is your occupation?

This concludes the survey. Thank you for your time. I know that your time is valuable.

If you have any questions or concerns, please, refer to the contact sheet for information on who to contact.