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Evaluating the Association between Serum
Concentrations of Per- and Polyfluoroalkyl Substances
(PFAS) and Symptoms and Diagnoses of Selected Acute
Viral Illnesses Adult (≥ 18 years of age) Follow-up
Please complete the survey below.
Thank you!
Form Approved
OMB No. 0923-xxxx
Exp. Date xx/xx/202x
ATSDR estimates the average public reporting burden for this collection of information as 25 minutes per response,
including the time for reviewing instructions, searching existing data/information sources, gathering and maintaining
the data/information 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 a 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 Information Collection Review
Office, 1600 Clifton Road NE, MS D-74, Atlanta, Georgia 30333; ATTN: PRA (0923-xxxx).
Introduction
This is the 1st follow-up survey for the PFAS and Viral Infections Study. The purpose of this study is to improve our
understanding of the relationship between the amount of PFAS in a person's blood and susceptibility to acute
(short-term) viral illnesses. This includes the COVID-19 virus as well as other viral illnesses. You enrolled in this study
and you completed the initial survey around [enter date]. We would now like to invite you to complete this follow-up
survey that is asking about the time period from (date) to (date).
Remember to look back at your symptom diary to remind yourself of any symptoms you may have experienced in
the time period from (date) to (date). The symptom diary will help you complete this survey more easily!
Please enter your participant identification number located on the Invitation Letter you received at the start of this
study.
__________________________________
Section 1. Instructions for completion and submission
This survey is divided into sections and should take about 25 minutes to complete. As you go through each section,
read each question carefully and answer as best as you can. If you have questions and would like to speak with a
member of the study team, please call xxx-xxx-xxxx or send an email with your question to xxx@xxx.xxx. Thank you
for being in this study.
Please remember, this survey is asking about the time period from (date) to (date).
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Section 2. Demographic and Health Information
In the time period from (date) to (date), did you get an Influenza vaccine (Flu shot)?
Yes
No
Prefer not to answer
When did you get that Influenza Vaccine (Flu shot)? Please enter month/day/year.
__________________________________
In the time period from (date) to (date), did you get a dose of a COVID-19 vaccine?
Yes
No
Prefer not to answer
When did you get that dose of a COVID-19 vaccine? Please enter month/day/year.
__________________________________
Which brand did you get for that dose of COVID-19 vaccine?
Pfizer
Moderna
Johnson & Johnson
Other
In the time period from (date) to (date), did you get another COVID-19 vaccine?
Yes
No
Prefer not to answer
When did you get that additional dose of a COVID-19 vaccine? Please enter month/day/year.
__________________________________
Which brand did you get for that additional dose of COVID-19 vaccine?
Pfizer
Moderna
Johnson & Johnson
Other
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In the time period from (date) to (date), have you received a brand new diagnosis by a doctor
or other health care professional of any of the chronic medical conditions listed in the chart
below?
New diagnosis
No new diagnosis
Prefer not to answer
Asthma
Chronic Obstructive Pulmonary
Disease (COPD)
Cystic Fibrosis
Other Chronic Lung Disease
(please specify below)
Hypertension (High Blood
Pressure)
Congenital (since birth) Heart
Disease
Chronic Heart Failure
Coronary Artery Disease
Cardiomyopathy
Other Heart / Cardiovascular
Disease (please specify below)
Diabetes (type 1 or 2)
Chronic Kidney Disease
Liver disease
Seasonal Allergies
Cancer
Currently on Chemotherapy
History of Bone Marrow or Stem
Cell Transplant
History of organ transplant
Immunocompromised state
(weakened immune system)
Sickle Cell Disease (Sickle Cell
Anemia)
Inherited Metabolic Disorders
Neurologic Disease (epilepsy /
seizure disorder)
Intellectual disability
Cerebral palsy
Dementia
Other Developmental Disability
(please specify below)
Depression
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Anxiety
If you selected "Other Chronic Lung Disease" above, please specify:
__________________________________
If you selected "Other Heart/Cardiovascular Disease" above, please specify:
__________________________________
If you selected "Other Developmental Disability" above, please specify:
__________________________________
Section 3. Similar to the survey you already completed, the questions in this section relate to
how often you are in situations that may increase your risk of exposure to viruses through
close contact with other people.
Including yourself, how many people live in your household? Please include individuals who sleep in the home at
least 2 nights per week; please do not include those who are living away from home for school.
__________________________________
How many children less than 5 years old live in your household?
__________________________________
How many children aged 5-11 years live in your household?
__________________________________
How many children aged 12-17 years live in your household?
__________________________________
How many adults aged 18-64 years live in your household?
__________________________________
How many adults aged 65 years and older live in your household?
__________________________________
How many bedrooms are in your house?
__________________________________
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Please answer the next six questions based on your average experience in the time period
from (date) to (date). If the question does not apply to you, please enter "0". (Note: the first
three questions ask for number of hours per week and the last 3 questions ask for number of
times per week)
On average, how many hours per week do you work in an indoor location that is not your home?
__________________________________
On average, how many hours per week do you attend school in person in an indoor classroom setting?
__________________________________
On average, how many hours per week are you in a situation that requires regular close contact (within 6 feet for a
total of 15 minutes or more) with people who do not live with you? Please do not include transportation here; it will
be asked in the next set of questions.
__________________________________
On average, how many times per week do you travel by bus or train in which the trip takes 15 minutes or longer?
__________________________________
On average, how many times per week do you carpool with people who do not live with you?
__________________________________
On average, how many times per week do you play sports or participate in other extracurricular activities (e.g.,
volunteer, social, or religious activities) indoors with other people that do not live with you?
__________________________________
Do you have children or adults living with you who are attending in-person daycare, school, college, or
technical/trade school? Please do not include those who are living away from home for school.
Yes
No
Don't know / Prefer not to answer
Are there other people living with you that work in person at an indoor location that is not your home?
Yes
No
Don't know / prefer not to answer
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Section 4. Viral Illness History
This section relates to symptoms of illness that might have been caused by viruses, as well as
medical care or medical testing you may have received for those illnesses. We are interested
in illnesses you experienced in the time period from (date) to (date) that included fever, chills,
respiratory symptoms (such as nasal congestion, runny nose, cough, shortness of breath or
sore throat), or gastrointestinal symptoms (such as nausea, vomiting, diarrhea or abdominal
pain).
For this section, an Episode of illness is one distinct period of time when you were sick or
experienced a set of symptoms. For example, Episode #1 (first episode) may represent an
illness in January and Episode #2 (second episode) may represent a different illness in March.
In addition, an Episode of illness would start when you first started to feel sick and would end
when you felt back to normal, even if the specific symptoms changed during that time (for
example, an illness might start with a sore throat and end with a cough).
In the time period from (date) to (date), have you had any episodes of illness?
Yes
No
Don't know
For the first episode of illness you had in the time period from (date) to (date), what was the approximate date when
the first symptom began:
__________________________________
For the first episode of illness you had in the time period from (date) to (date), did you have
any of the following symptoms?
Yes
No
Fever (100 degrees or higher
measured with a thermometer)
Felt feverish (even if you did not
take your temperature with a
thermometer)
Chills or repeated shaking with
chills
Cough
Shortness of breath or difficulty
breathing
Nasal congestion (stuffy or
blocked nose)
Runny nose
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Sore throat
New loss of taste or smell
Headache
Fatigue
Muscle pains or body aches
Nausea or stomach upset
Abdominal pain
Vomiting
Diarrhea
Unexplained rash
For this first episode of illness, please enter the number of days that you had each of the your symptoms.
Fever (100 degrees or higher measured with a thermometer)
__________________________________
Felt feverish (even if you did not take your temperature with a thermometer)
__________________________________
Chills or repeated shaking with chills
__________________________________
Cough
__________________________________
Shortness of breath or difficulty breathing
__________________________________
Nasal congestion (stuffy or blocked nose)
__________________________________
Runny nose
__________________________________
Sore throat
__________________________________
New loss of taste or smell
__________________________________
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Headache
__________________________________
Fatigue
__________________________________
Muscle pains or body aches
__________________________________
Nausea or stomach upset
__________________________________
Abdominal pain
__________________________________
Vomiting
__________________________________
Diarrhea
__________________________________
Unexplained rash
__________________________________
For the first episode of illness you had in the time period from (date) to (date), did you travel
using the following modes of transportation in the 14 days before onset of symptoms? Please
don't include local daily travel for work, school, or routine activities such as grocery shopping.
Yes
No
Prefer not to answer
Bus
Train
Airplane
For the first episode of illness you had in the time period from (date) to (date), did you seek and/or receive medical
care or testing for your symptoms?
Yes
No
Prefer not to answer
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If you answered YES to the previous question, please answer the remaining questions in this
table.
Yes
No
Prefer not to answer
Did you receive in-person care
or testing at a physician's or
other healthcare provider's
office?
Did you receive care or testing
from a physician's or other
healthcare provider's office
using Telehealth (by phone or
computer)?
Did you receive care or testing
at a Pharmacy (testing or
treatment by a pharmacist or at
a clinic located at/within a
pharmacy)?
Did you receive care or testing
at an Urgent Care Clinic?
Did you receive care or testing
at a drive-thru/drive-up testing
site?
Did you receive care or testing
at a Hospital Emergency
Department (ER)?
Were you hospitalized overnight
for your symptoms? (not ER)
Did you receive a diagnosis from a physician?
Yes
No
If yes, what was the diagnosis?
__________________________________
For the first episode of illness, in the time period from (date) to (date), were any of the
following tests performed? And what were the results? Please choose one best answer for
each of the tests listed. (+) indicates any positive test and (-) indicates only negative tests.
For example, if you had two flu tests performed for this first episode of illness and one was
negative and one was positive, please mark the column labeled 'Any positive test (+)'. For the
chest x-ray, (+) result means an abnormal result and (-) means a normal result.
Not done
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Any positive test (+)
Only negative tests (-)
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Indeterminant or
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Influenza (flu) nasal swab test
Respiratory Syncytial Virus (RSV)
nasal swab test
Nasal swab for other viruses (not
including COVID-19)
Strep test (throat swab)
Chest x-ray
COVID-19 diagnostic test: nasal
swab, nasopharyngeal swab,
mouth or throat swab, saliva test
COVID-19 blood test (serology or
antibody test)
Have you had more than one episode of illness in the time period from (date) to (date)?
Yes
No
For the second episode of illness you had in the time period from (date) to (date), what was the approximate date
when the first symptom began:
__________________________________
For the second episode of illness you had in the time period from (date) to (date), did you had
any of the following symptoms?
Yes
No
Fever (100 degrees or higher
measured with a thermometer)
Felt feverish (even if you did not
take your temperature with a
thermometer)
Chills or repeated shaking with
chills
Cough
Shortness of breath or difficulty
breathing
Nasal congestion (stuffy or
blocked nose)
Runny nose
Sore throat
New Loss of taste or smell
Headache
Fatigue
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Muscle pains or body aches
Nausea or stomach upset
Abdominal pain
Vomiting
Diarrhea
Unexplained rash
For this second episode of illness, please indicate the number of days that you had each of the your symptoms?
Fever (100 degrees or higher measured with a thermometer)
__________________________________
Felt feverish (even if you did not take your temperature with a thermometer)
__________________________________
Chills or repeated shaking with chills
__________________________________
Cough
__________________________________
Shortness of breath or difficulty breathing
__________________________________
Nasal congestion (stuffy or blocked nose)
__________________________________
Runny nose
__________________________________
Sore throat
__________________________________
New loss of taste or smell
__________________________________
Headache
__________________________________
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Fatigue
__________________________________
Muscle pains or body aches
__________________________________
Nausea or stomach upset
__________________________________
Abdominal pain
__________________________________
Vomiting
__________________________________
Diarrhea
__________________________________
Unexplained rash
__________________________________
For the second episode of illness you had in the time period from (date) to (date), did you
travel using the following modes of transportation in the 14 days before onset of symptoms?
Please don't include local daily travel for work, school, or routine activities such as grocery
shopping.
Yes
No
Prefer not to answer
Bus
Train
Airplane
For the second episode of illness you had in the time period from (date) to (date), did you seek and/or receive
medical care or testing for your symptoms?
Yes
No
Prefer not to answer
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If you answered YES to the previous question, please answer the remaining questions in this
table.
Yes
No
Prefer not to answer
Did you receive in-person care
or testing at a physician's or
other healthcare provider's
office?
Did you receive care or testing
from a physician's or other
healthcare provider's office
using Telehealth (by phone or
computer)?
Did you receive care or testing
at a Pharmacy (testing or
treatment by a pharmacist or at
a clinic located at/within a
pharmacy)?
Did you receive care or testing
at an Urgent Care Clinic?
Did you receive care or testing
at a drive-thru/drive-up testing
site?
Did you receive care or testing
at a Hospital Emergency
Department (ER)?
Were you hospitalized overnight
for your symptoms? (not ER)?
Did you receive a diagnosis from a physician?
Yes
No
If yes, what was the diagnosis?
__________________________________
For the second episode of illness, in the time period from (date) to (date), were any of the
following tests performed? And what were the results? Please choose one best answer for
each of the tests listed. (+) indicates any positive test and (-) indicates only negative tests.
For example, if you had two flu tests performed for this second episode of illness and one was
negative and one was positive, please mark the column labeled 'Any positive test (+)'. For the
chest x-ray, (+) result means an abnormal result and (-) means a normal result.
Not done
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Any positive test (+)
Only negative tests (-)
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Indeterminant or
don't know
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Page 14
Influenza (flu) nasal swab test
Respiratory Syncytial Virus (RSV)
nasal swab test
Nasal swab for other viruses (not
including COVID-19)
Strep test (throat swab)
Chest x-ray
COVID-19 diagnostic test: nasal
swab, nasopharyngeal swab,
mouth or throat swab, saliva test
COVID-19 blood test (serology or
antibody test)
Have you had more than two episodes of illness in the time period from (date) to (date)?
Yes
No
For the third episode of illness you had in the time period from (date) to (date), what was the approximate date when
the first symptom began:
__________________________________
For the third episode of illness you had in the time period from (date) to (date), did you had
any of the following symptoms?
Yes
No
Fever (100 degrees or higher
measured with a thermometer)
Felt feverish (even if you did not
take your temperature with a
thermometer)
Chills or repeated shaking with
chills
Cough
Shortness of breath or difficulty
breathing
Nasal congestion (stuffy or
blocked nose)
Runny nose
Sore throat
New Loss of taste or smell
Headache
Fatigue
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Muscle pains or body aches
Nausea or stomach upset
Abdominal pain
Vomiting
Diarrhea
Unexplained rash
For the third episode of illness, please indicate the number of days that you had each of the your symptoms?
Fever (100 degrees or higher measured with a thermometer)
__________________________________
Felt feverish (even if you did not take your temperature with a thermometer)
__________________________________
Chills or repeated shaking with chills
__________________________________
Cough
__________________________________
Shortness of breath or difficulty breathing
__________________________________
Nasal congestion (stuffy or blocked nose)
__________________________________
Runny nose
__________________________________
Sore throat
__________________________________
New loss of taste or smell
__________________________________
Headache
__________________________________
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Fatigue
__________________________________
Muscle pains or body aches
__________________________________
Nausea or stomach upset
__________________________________
Abdominal pain
__________________________________
Vomiting
__________________________________
Diarrhea
__________________________________
Unexplained rash
__________________________________
For the third episode of illness you had in the time period from (date) to (date), did you travel
using the following modes of transportation in the 14 days before onset of symptoms? Please
don't include local daily travel for work, school, or routine activities such as grocery shopping.
Yes
No
Prefer not to answer
Bus
Train
Airplane
For this third episode of illness you had in the time period from (date) to (date), did you seek and/or receive medical
care or testing for your symptoms?
Yes
No
Prefer not to answer
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If you answered YES to the previous question, please answer the remaining questions in this
table.
Yes
No
Prefer not to answer
Did you receive in-person care
or testing at a physician's or
other healthcare provider's
office?
Did you receive care or testing
from a physician's or other
healthcare provider's office
using Telehealth (by phone or
computer)?
Did you receive care or testing
at a Pharmacy (testing or
treatment by a pharmacist or at
a clinic located at/within a
pharmacy)?
Did you receive care or testing
at an Urgent Care Clinic?
Did you receive care or testing
at a drive-thru/drive-up testing
site?
Did you receive care or testing
at a Hospital Emergency
Department (ER)?
Were you hospitalized overnight
for your symptoms? (not ER)?
Did you receive a diagnosis from a physician?
Yes
No
If yes, what was the diagnosis?
__________________________________
For the third episode of illness, in the time period from (date) to (date), were any of the
following tests performed? And what were the results? Please choose one best answer for
each of the tests listed. (+) indicates any positive test and (-) indicates only negative tests.
For example, if you had two flu tests performed for this third episode of illness and one was
negative and one was positive, please mark the column labeled 'Any positive test (+)'. For the
chest x-ray, (+) result means an abnormal result and (-) means a normal result.
Not done
11/12/2021 2:22pm
Any positive test (+)
Only negative tests (-)
projectredcap.org
Indeterminant or
don't know
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Page 18
Influenza (flu) nasal swab test
Respiratory Syncytial Virus (RSV)
nasal swab test
Nasal swab for other viruses (not
including COVID-19)
Strep test (throat swab)
Chest x-ray
COVID-19 diagnostic test: nasal
swab, nasopharyngeal swab,
mouth or throat swab, saliva test
COVID-19 blood test (serology or
antibody test)
Have you had more than three episodes of illness in the time period from (date) to (date)?
Yes
No
Section 5. Questions specific to COVID-19
This section relates to COVID-19 or a COVID-19-like illness. The items listed below could have
happened more than once. For each question you answer "Yes", please indicate, to the best
of your recollection, the number of times and the approximate dates, starting with the
earliest, that the item occurred in the time period from (date) to (date). Enter the dates using
2 digits for the month and 4 digits for the year. If you are entering multiple dates for an item,
please separate each by a comma. (Example: 01/2020, 02/2020)
For questions below that ask about COVID-19 testing, please note:
There are different types of COVID-19 tests available. Some test for current infection and
some test for past infection.
A viral test tells you if you have a current infection. Two types of viral tests can be used:
nucleic acid amplification tests (often called PCR tests) and antigen tests. The viral test
involves collecting a specimen with a swab from the nose, nasopharynx, mouth, or throat; or
collecting saliva.
An antibody test (also known as a serology test) is a blood test that might tell you if you had a
past infection. Antibody tests are not used to diagnose a current infection.
Were you in close contact (defined as within 6 feet for a total of 15 minutes or more) with a person who you know
had active COVID-19 that was confirmed with a positive COVID-19 viral test?
Yes
No
If you answered yes, how many times?
__________________________________
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Please list the approximate dates in month and year (mm/yyyy).
__________________________________
Were you in close contact (defined as within 6 feet for a total of 15 minutes or more) with a person who you suspect
had active COVID-19, but who (to your knowledge) did not have COVID-19 confirmed with a positive COVID-19 viral
test?
Yes
No
If you answered yes, how many times?
__________________________________
Please list the approximate dates in month and year (mm/yyyy).
__________________________________
Have you been advised to self-quarantine (separate yourself from others and monitor for signs of infection for 10-14
days) because of exposure to someone with a positive COVID-19 viral test?
Yes
No
If you answered yes, how many times?
__________________________________
Please list the approximate dates in month and year (mm/yyyy).
__________________________________
Have you provided care for someone who had a positive viral test for COVID-19 at the time you were providing care?
Yes
No
If you answered yes, how many times?
__________________________________
Please list the approximate dates in month and year (mm/yyyy).
__________________________________
Have you had a positive viral test for COVID-19 while having no symptoms?
Yes
No
If you answered yes, how many times?
__________________________________
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Please list the approximate dates in month and year (mm/yyyy).
__________________________________
Have you had an antibody blood test for COVID-19 (either positive or negative)?
Yes
No
If you answered yes, how many times?
__________________________________
Please list the approximate dates in month and year (mm/yyyy).
__________________________________
Have you had an antibody blood test for COVID-19 that was positive (indicated that you had antibodies to
COVID-19)?
Yes
No
If you answered yes, how many times?
__________________________________
Please list the approximate dates in month and year (mm/yyyy).
__________________________________
Besides you, has anyone else in your household had an illness that you suspected was COVID-19 but for which they
did not receive testing for COVID-19?
Yes
No
If you answered yes, how many times?
__________________________________
Please list the approximate dates in month and year (mm/yyyy).
__________________________________
Besides you, has anyone else in your household been tested with a viral test for COVID-19?
Yes
No
If you answered yes, how many times?
__________________________________
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Please list the approximate dates in month and year (mm/yyyy).
__________________________________
Besides you, has anyone else in your household had a positive viral test for COVID-19 while having no symptoms?
Yes
No
If you answered yes, how many times?
__________________________________
Please list the approximate dates in month and year (mm/yyyy).
__________________________________
Besides you, has anyone else in your household had a positive viral test for COVID-19 while having symptoms?
Yes
No
If you answered yes, how many times?
__________________________________
Please list the approximate dates in month and year (mm/yyyy).
__________________________________
Date on which this survey was completed:
__________________________________
Important note before you go:
Please take a moment to start the new symptom diary (attached). Please use this symptom diary to help you track
your symptoms during the time period from (date) to (date). Using the symptom diary in between the surveys will
help you complete the next survey more easily.
(Attach symptom diary with date span for 2nd follow-up survey to this field)
Please confirm your email address (it should be the same email address you provided for this survey) :
(Please remember, you must have your own, unique email address).
__________________________________
Thank you for completing this survey! Be on the look out for the next survey coming in about 3 months.
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| File Type | application/pdf |
| File Modified | 2021-11-12 |
| File Created | 2021-11-12 |