Form 0923-22BJ Child Follow-up Survey

Confidential

Page 1

Evaluating the Association between Serum
Concentrations of Per- and Polyfluoroalkyl Substances
(PFAS) and Symptoms and Diagnoses of Selected Acute
Viral Illnesses Child (< 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 your child in
this study and the initial survey was completed around [enter date]. We would now like to invite you to complete
this follow-up survey about your child that is asking about the time period from (date) to (date).
Remember to look back at your child's symptom diary as a reminder of any symptoms your child may have
experienced in the time period from (date) to (date). The symptom diary will help you and your child complete this
survey more easily!
Please enter your child's 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 allowing your child to be 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 your child get an Influenza vaccine (Flu shot)?
Yes
No
Prefer not to answer
When did your child get that Influenza Vaccine (Flu shot)? Please enter month/day/year.
__________________________________
In the time period from (date) to (date), did your child get a dose of a COVID-19 vaccine?
Yes
No
Prefer not to answer
Child not eligible due to age
When did your child get that dose of a COVID-19 vaccine? Please enter month/day/year.
__________________________________
Which brand did your child get for that dose of COVID-19 vaccine?
Pfizer
Moderna
Johnson & Johnson
Other
In the time period from (date) to (date), did your child get another COVID-19 vaccine?
Yes
No
Prefer not to answer
When did your child get that additional dose of a COVID-19 vaccine? Please enter month/day/year.
__________________________________
Which brand did your child get for that additional dose of a COVID-19 vaccine?
Pfizer
Moderna
Johnson & Johnson
Other

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In the time period from (date) to (date), has your child 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 / stem
cell transplant
History of Organ Transplant
Immunocompromised state
(weakened immune system)
Sickle Cell Disease (Sickle Cell
Anemia)
Inherited Metabolic Disorders
Neurological Disease (epilepsy /
seizure disorder)
Intellectual Disability
Cerebral palsy
Other Developmental Disability
(please specify below)
Depression
Anxiety
If you selected "Other Chronic Lung Disease" above, please specify:
__________________________________

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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 already completed, the questions in this section relate to how
often your child is in situations that may increase the risk of exposure to viruses through close
contact with other people.
Please remember: If you are a parent filling this survey out for your child, questions about
"anyone else in the household" refers to anyone besides the child you are answering the
questions for (including yourself). If your child lives in more than one home, please answer the
next series of questions based on the household that qualified the child for the previous
ATSDR-funded study (i.e., Exposure Assessment, PEATT Study, or Pease Study). If the child
lives in more than one home that qualified for these previous studies, please answer the
questions based on the household with the most people.
Including your child, how many people live in your child's 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 child's household?
__________________________________
How many children aged 5-11 years live in your child's household?
__________________________________
How many children aged 12-17 years live in your child's household?
__________________________________
How many adults aged 18-64 years live in your child's household?
__________________________________
How many adults aged 65 years and older live in your child's household?
__________________________________
How many bedrooms are in your child's house?
__________________________________
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Please answer the next six questions based on your child's average experience in the time
period from (date) to (date). If the question does not apply to your child, 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 does your child work or play in an indoor location that is not your child's
home?
__________________________________
On average, how many hours per week does your child attend school or daycare in person in an indoor classroom
setting?
__________________________________
On average, how many hours per week is your child 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 your child? Please do not include transportation
here; it will be asked in the next set of questions.
__________________________________
On average, how many times per week does your child travel by bus or train in which the trip takes 15 minutes or
longer?
__________________________________
On average, how many times per week does your child ride in a car with people who do not live with your child?
__________________________________
On average, how many times per week does your child play sports or participate in other extracurricular activities
(band, clubs, camp, etc.) indoors with other people that do not live with your child?
__________________________________
Does your child have other children or adults living with him/her 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 your child that work in person at an indoor location that is not your child's 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 your child may have received for those illnesses. We are
interested in illnesses your child 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 your child was 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 your child first started to feel sick and
would end when your child 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), has your child had any episodes of illness?
Yes
No
Don't know
For the first episode of illness your child 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 your child had in the time period from (date) to (date), did
he/she 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 child's 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 your child had each of his/her symptoms?
Fever (100 degrees or higher measured with a thermometer)
__________________________________
Felt feverish (even if you did not take your child's 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 your child had in the time period from (date) to (date), did your
child 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

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For the first episode of illness your child had in the time period from (date) to (date), did you seek and/or receive
medical care or testing for your child's symptoms?
Yes
No
Prefer not to answer

If you answered YES to the previous question, please answer the remaining questions in this
table.
Yes

No

Prefer not to answer

Did your child receive in-person
care or testing at a physician's
or other healthcare provider's
office?
Did your child receive care or
testing from a physician's or
other healthcare provider's
office using Telehealth (by
phone or computer)?
Did your child receive care or
testing at a Pharmacy (testing or
treatment by a pharmacist or at
a clinic located at/within a
pharmacy)?
Did your child receive care or
testing at an Urgent Care Clinic?
Did you receive care or testing
at a drive-thru/drive-up testing
site?
Did your child receive care or
testing at a Hospital Emergency
Department (ER)?
Was your child hospitalized
overnight for his/her symptoms?
(not ER)?

Did your child receive a diagnosis from a physician?
Yes
No
Prefer not to answer
If yes, what was the diagnosis?
__________________________________

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For the first episode of illness, in the time period from (date) to (date), did your child have
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 your child 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

Any positive test (+)

Only negative tests (-)

Indeterminant or
don't know

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)

Has your child had more than one episode of illness in the time period from (date) to (date)?
Yes
No
Don't know
For the second episode of illness your child 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 your child had in the time period from (date) to (date), did
he/she 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 child's temperature
with a thermometer)
Chills or repeated shaking with
chills

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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
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 your child had each of his/her symptoms.
Fever (100 degrees or higher measured with a thermometer)
__________________________________
Felt feverish (even if you did not take your child's 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 upset stomach
__________________________________
Abdominal pain
__________________________________
Vomiting
__________________________________
Diarrhea
__________________________________
Unexplained rash
__________________________________

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For the second episode of illness your child had in the time period from (date) to (date), did
your child 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 your child had in the time period from (date) to (date), did you seek and/or receive
medical care or testing for your child's symptoms?
Yes
No
Prefer not to answer

If you answered YES to the previous question, please answer the remaining questions in this
table.
Yes

No

Prefer not to answer

Did your child receive in-person
care or testing at a physician's
or other healthcare provider's
office?
Did your child receive care or
testing from a physician's or
other healthcare provider's
office using Telehealth (by
phone or computer)?
Did your child receive care or
testing at a Pharmacy (testing or
treatment by a pharmacist or at
a clinic located at/within a
pharmacy)?
Did your child receive care or
testing at an Urgent Care Clinic?
Did you receive care or testing
at a drive-thru/drive-up testing
site?
Did your child receive care or
testing at a Hospital Emergency
Department (ER)?
Was your child hospitalized
overnight for his/her symptoms?
(not ER)?

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Did your child receive a diagnosis from a physician?
Yes
No
Prefer not to answer
If yes, what was the diagnosis?
__________________________________

For the second episode of illness, in the time period from (date) to (date), did your child have
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 your child 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

Any positive test (+)

Only negative tests (-)

Indeterminant or
don't know

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)

Has your child had more than two episodes of illness in the time period from (date) to (date)?
Yes
No
Don't know
For the third episode of illness your child had in the time period from (date) to (date), what was the approximate date
when the first symptom began?
__________________________________

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For the third episode of illness your child had in the time period from (date) to (date), did
he/she 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 child's 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
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 your child had each of his/her symptoms?
Fever (100 degrees or higher measured with a thermometer)
__________________________________
Felt feverish (even if you did not take your child's temperature with a thermometer)
__________________________________
Chill or repeated shaking chills
__________________________________
Cough
__________________________________
Shortness of breath or breathing difficulty
__________________________________
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Nasal congestion (stuffy or blocked nose)
__________________________________
Runny nose
__________________________________
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
__________________________________

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For the third episode of illness in the time period from (date) to (date), did your child 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 third episode of illness your child had in the time period from (date) to (date), did you seek and/or receive
medical care or testing for your child's symptoms?
Yes
No
Prefer not to answer

If you answered YES to the previous question, please answer the remaining questions in this
table.
Yes

No

Prefer not to answer

Did your child receive in-person
care or testing at a physician's
or other healthcare provider's
office?
Did your child receive care or
testing from a physician's or
other healthcare provider's
office using Telehealth (by
phone or computer)?
Did your child receive care or
testing at a Pharmacy (testing or
treatment by a pharmacist or at
a clinic located at/within a
pharmacy)?
Did your child receive care or
testing at an Urgent Care Clinic?
Did you receive care or testing
at a drive-thru/drive-up testing
site?
Did your child receive care or
testing at a Hospital Emergency
Department (ER)?
Was your child hospitalized
overnight for his/heryour
symptoms? (not ER)?

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Did your child receive a diagnosis from a physician?
Yes
No
Prefer not to answer
If yes, what was the diagnosis?
__________________________________

For the third episode of illness, in the time period from (date) to (date), did your child have
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 your child 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

Any positive test (+)

Only negative tests (-)

Indeterminant or
don't know

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)

Has your child 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
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A viral test tells you if your child has 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 your child
had a past infection. Antibody tests are not used to diagnose a current infection.
Please remember: If you are a parent filling this survey out for your child, questions about
"anyone else in the household" refers to anyone besides the child you are answering the
questions for (including yourself).
Was your child 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?
__________________________________
Please list the approximate dates in month and year (mm/yyyy).
__________________________________
Was your child 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 quarantine your child (separate your child 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?
__________________________________

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Please list the approximate dates in month and year (mm/yyyy).
__________________________________
Has your child helped to provide care for someone who had a positive viral test for COVID-19 at the time your child
helped to provide care?
Yes
No
If you answered yes, how many times?
__________________________________
Please list the approximate dates in month and year (mm/yyyy).
__________________________________
Has your child 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).
__________________________________
Has your child 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).
__________________________________
Has your child had an antibody blood test for COVID-19 that was positive (indicated that he/she had antibodies to
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 your child, has anyone else in your child's 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 your child, has anyone else in your child's household been tested with a viral test for COVID-19?
Yes
No
If you answered yes, how many times?
__________________________________
Please list the approximate dates in month and year (mm/yyyy).
__________________________________
Besides your child, has anyone else in your child's 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 your child, has anyone else in your child's household had a positive viral test for COVID-19 while having
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).
__________________________________
Date on which survey was completed:
__________________________________
Important note before you go:
Please take a moment to start a new symptom diary for your child (attached). Please use this symptom diary to help
track your child's symptoms during the time period from (date) to (date). Using the symptom diary in between the
surveys will help you complete your child's next survey more easily.
(Attach symptom diary with date span for 2nd follow-up survey to this field)
Please confirm your child's email address (it should be the same email address you provided for this survey) :
(Please remember, your child must have his/her own unique email address).
__________________________________
Thank you and your child for completing this survey! Be on the look out for the next survey coming in about 3
months.

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