0923-0064 Evaluating the Association between Serum Concentrations

[ATSDR] Evaluating the Association between Serum Concentrations of Per- and Polyfluoroalkyl Substances (PFAS) and Symptoms and Diagnoses of Selected Acute Viral Illnesses

P_ApndxC_F-UAdltSrvy (Word)_20221213

OMB: 0923-0064

Document [docx]
Download: docx | pdf

Page 1


Appendix C. Follow-up Adult Survey (Word)


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. 0923-0064

Exp. Date 09/30/2025


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/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 (0923-0064).


Shape3

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.



Shape5


Shape6

This survey is divided into sections and should take about 30 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 [email protected]. Thank you for being in this study.


Please remember, this survey is asking about the time period from (date) to (date).


Shape7

Have you moved to a different address since completing the last survey?


Shape8 Yes No

Prefer not to answer


In the time period from (date) to (date), did you get an Influenza vaccine (Flu shot)?


Shape10 Yes No

Prefer not to answer


When did you get that Influenza Vaccine (Flu shot)? Please enter month/day/year.


Shape12


In the time period from (date) to (date), did you get a dose of a COVID-19 vaccine?


Shape14 Yes No

Prefer not to answer


When did you get that dose of a COVID-19 vaccine? Please enter month/day/year.


Shape16


Which brand did you get for that dose of COVID-19 vaccine?


Shape18 Pfizer Moderna

Johnson & Johnson Other


In the time period from (date) to (date), did you get another COVID-19 vaccine?


Shape20 Yes No

Prefer not to answer


When did you get that additional dose of a COVID-19 vaccine? Please enter month/day/year.


Shape22


Which brand did you get for that additional dose of COVID-19 vaccine?


Shape24 Pfizer Moderna

Johnson & Johnson Other


Shape25

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


Anxiety


If you selected "Other Chronic Lung Disease" above, please specify:


Shape27


If you selected "Other Heart/Cardiovascular Disease" above, please specify:


Shape29


If you selected "Other Developmental Disability" above, please specify:


Shape31


Shape32

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.


Shape33


How many children less than 5 years old live in your household?


Shape35


How many children aged 5-11 years live in your household?


Shape37


How many children aged 12-17 years live in your household?


Shape39


How many adults aged 18-64 years live in your household?


Shape41


How many adults aged 65 years and older live in your household?


Shape43



Shape45

On average, how many hours per week do you work in an indoor location that is not your home?


Shape46


On average, how many hours per week do you attend school in person in an indoor classroom setting?


Shape48


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.


Shape50


On average, how many times per week do you travel by bus or train in which the trip takes 15 minutes or longer?


Shape52


On average, how many times per week do you carpool with people who do not live with you?


Shape54


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?


Shape56


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.


Shape58 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?


Shape60 Yes No

Don't know / prefer not to answer


Shape61

In the time period from (date) to (date), have you had any episodes of illness?


Shape62 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:


Shape64


Shape65

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 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)


Shape68


Felt feverish (even if you did not take your temperature with a thermometer)


Shape70


Chills or repeated shaking with chills


Shape72


Cough


Shape74


Shortness of breath or difficulty breathing


Shape76


Nasal congestion (stuffy or blocked nose)


Shape78


Runny nose


Shape80


Sore throat


Shape82


New loss of taste or smell


Shape84


Headache


Shape86


Fatigue


Shape88


Muscle pains or body aches


Shape90


Nausea or stomach upset


Shape92


Abdominal pain


Shape94


Vomiting


Shape96


Diarrhea


Shape98


Unexplained rash


Shape100


Shape101

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?


Shape103 Yes No

Prefer not to answer


Shape104

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?


Shape106 Yes No


If yes, what was the diagnosis?


Shape108


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.



Influenza (flu) nasal swab test

Not done


Any positive test (+) Only negative tests (-)


Indeterminant or don't know


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)?


Shape110 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:



Shape112


Shape113

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 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)


Shape116


Felt feverish (even if you did not take your temperature with a thermometer)


Shape118


Chills or repeated shaking with chills


Shape120


Cough


Shape122


Shortness of breath or difficulty breathing


Shape124


Nasal congestion (stuffy or blocked nose)


Shape126


Runny nose


Shape128


Sore throat


Shape130


New loss of taste or smell


Shape132


Headache


Shape134


Fatigue


Shape136


Muscle pains or body aches


Shape138


Nausea or stomach upset


Shape140


Abdominal pain


Shape142


Vomiting


Shape144


Diarrhea


Shape146


Unexplained rash


Shape148


Shape149

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?


Shape151 Yes No

Prefer not to answer


Shape152

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?


Shape154 Yes No


If yes, what was the diagnosis?


Shape156


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.



Influenza (flu) nasal swab test

Not done


Any positive test (+) Only negative tests (-)


Indeterminant or don't know


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)?


Shape158 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:


Shape160


Shape161

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 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)


Shape164


Felt feverish (even if you did not take your temperature with a thermometer)


Shape166


Chills or repeated shaking with chills


Shape168


Cough


Shape170


Shortness of breath or difficulty breathing


Shape172


Nasal congestion (stuffy or blocked nose)


Shape174


Runny nose


Shape176


Sore throat


Shape178


New loss of taste or smell


Shape180


Headache


Shape182


Fatigue


Shape184


Muscle pains or body aches


Shape186


Nausea or stomach upset


Shape188


Abdominal pain


Shape190


Vomiting


Shape192


Diarrhea


Shape194


Unexplained rash


Shape196


Shape197

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?


Shape199 Yes No

Prefer not to answer


Shape200

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?


Shape202 Yes No


If yes, what was the diagnosis?


Shape204


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.



Influenza (flu) nasal swab test

Not done


Any positive test (+) Only negative tests (-)


Indeterminant or don't know


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)?


Shape206 Yes

No (skip to Section 5)


Shape207

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 Muscle pains or body aches Nausea or stomach upset Abdominal pain Vomiting Diarrhea Unexplained rash


For the fourth episode of illness, please indicate the number of days that you had each of your symptoms?


Fever (100 degrees or higher measured with a thermometer)


Shape210


Felt feverish (even if you did not take your temperature with a thermometer)


Shape212


Chills or repeated shaking with chills


Shape214


Cough


Shape216


Shortness of breath or difficulty breathing


Shape218


Nasal congestion (stuffy or blocked nose)


Shape220


Runny nose


Shape222


Sore throat


Shape224


New loss of taste or smell


Shape226


Headache


Shape228


Fatigue


Shape230


Muscle pains or body aches


Shape232


Nausea or stomach upset


Shape234


Abdominal pain


Shape236


Vomiting


Shape238


Diarrhea


Shape240


Unexplained rash


Shape242


Shape243

Yes No Prefer not to answer

Bus Train Airplane


For this fourth 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?


Shape245 Yes No

Prefer not to answer


Shape246

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?


Shape248 Yes No


If yes, what was the diagnosis?


Shape250


For the fourth 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 fourth 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.



Influenza (flu) nasal swab test

Not done


Any positive test (+) Only negative tests (-)


Indeterminant or don't know


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 four episodes of illness in the time period from (date) to (date)?


Shape252 Yes

No (skip to Section 5)



Shape253

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 Muscle pains or body aches Nausea or stomach upset Abdominal pain Vomiting Diarrhea Unexplained rash


For the fifth episode of illness, please indicate the number of days that you had each of your symptoms?


Fever (100 degrees or higher measured with a thermometer)


Shape256


Felt feverish (even if you did not take your temperature with a thermometer)


Shape258


Chills or repeated shaking with chills


Shape260


Cough


Shape262


Shortness of breath or difficulty breathing


Shape264


Nasal congestion (stuffy or blocked nose)


Shape266


Runny nose


Shape268


Sore throat


Shape270


New loss of taste or smell


Shape272


Headache


Shape274


Fatigue


Shape276


Muscle pains or body aches


Shape278


Nausea or stomach upset


Shape280


Abdominal pain


Shape282


Vomiting


Shape284


Diarrhea


Shape286


Unexplained rash


Shape288


Shape289

Yes No Prefer not to answer

Bus Train Airplane


For this fifth 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?


Shape291 Yes No

Prefer not to answer


Shape292

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?


Shape294 Yes No


If yes, what was the diagnosis?


Shape296


For the fifth 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 fifth 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.



Influenza (flu) nasal swab test

Not done


Any positive test (+) Only negative tests (-)


Indeterminant or don't know


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 five episodes of illness in the time period from (date) to (date)?


Shape298 Yes (proceed to next question)

No (skip to Section 5)




Shape299

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 Muscle pains or body aches Nausea or stomach upset Abdominal pain Vomiting Diarrhea Unexplained rash


For the sixth 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)


Shape302


Felt feverish (even if you did not take your temperature with a thermometer)


Shape304


Chills or repeated shaking with chills


Shape306


Cough


Shape308


Shortness of breath or difficulty breathing


Shape310


Nasal congestion (stuffy or blocked nose)


Shape312


Runny nose


Shape314


Sore throat


Shape316


New loss of taste or smell


Shape318


Headache


Shape320


Fatigue


Shape322


Muscle pains or body aches


Shape324


Nausea or stomach upset


Shape326


Abdominal pain


Shape328


Vomiting


Shape330


Diarrhea


Shape332


Unexplained rash


Shape334


Shape335

Yes No Prefer not to answer

Bus Train Airplane


For this sixth 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?


Shape337 Yes No

Prefer not to answer


Shape338

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?


Shape340 Yes No


If yes, what was the diagnosis?


Shape342


For the sixth 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 sixth 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.



Influenza (flu) nasal swab test

Not done


Any positive test (+) Only negative tests (-)


Indeterminant or don't know


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)




Shape344 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?


Shape345 Yes No


If you answered yes, how many times?


Shape347


Please list the approximate dates in month and year (mm/yyyy).


Shape349


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?


Shape351 Yes No


If you answered yes, how many times?


Shape353


Please list the approximate dates in month and year (mm/yyyy).


Shape355


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?


Shape357 Yes No


If you answered yes, how many times?


Shape359


Please list the approximate dates in month and year (mm/yyyy).


Shape361


Have you provided care for someone who had a positive viral test for COVID-19 at the time you were providing care?


Shape363 Yes No


If you answered yes, how many times?


Shape365


Please list the approximate dates in month and year (mm/yyyy).


Shape367


Have you had a positive viral test for COVID-19 while having no symptoms?


Shape369 Yes No


If you answered yes, how many times?


Shape371


Please list the approximate dates in month and year (mm/yyyy).


Shape373


Have you had an antibody blood test for COVID-19 (either positive or negative)?


Shape375 Yes No


If you answered yes, how many times?


Shape377


Please list the approximate dates in month and year (mm/yyyy).


Shape379


Have you had an antibody blood test for COVID-19 that was positive (indicated that you had antibodies to COVID-19)?


Shape381 Yes No


If you answered yes, how many times?


Shape383


Please list the approximate dates in month and year (mm/yyyy).


Shape385


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?


Shape387 Yes No


If you answered yes, how many times?


Shape389


Please list the approximate dates in month and year (mm/yyyy).


Shape391


Besides you, has anyone else in your household been tested with a viral test for COVID-19?


Shape393 Yes No


If you answered yes, how many times?


Shape395


Please list the approximate dates in month and year (mm/yyyy).


Shape397


Besides you, has anyone else in your household had a positive viral test for COVID-19 while having no symptoms?


Shape399 Yes No


If you answered yes, how many times?


Shape401


Please list the approximate dates in month and year (mm/yyyy).


Shape403


Besides you, has anyone else in your household had a positive viral test for COVID-19 while having symptoms?


Shape405 Yes No


If you answered yes, how many times?


Shape407


Please list the approximate dates in month and year (mm/yyyy).


Shape409


Date on which this survey was completed:


Shape411


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).

Shape414


Thank you for completing this survey! Be on the look out for the next survey coming in about 3 months.


File Typeapplication/vnd.openxmlformats-officedocument.wordprocessingml.document
File Modified0000-00-00
File Created2023-08-26

© 2024 OMB.report | Privacy Policy