0923-0064 Evaluating the Association between Serum Concentrations

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).

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.

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).

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

Yes No

Prefer not to answer

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

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:

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

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

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?

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

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:

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)

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

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

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.
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)?

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:

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)

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

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

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.
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)?

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:

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)

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

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

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.
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)?

Yes

No (skip to Section 5)

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)

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

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?

Yes No

Prefer not to answer

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 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)?

Yes

No (skip to Section 5)

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)

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

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?

Yes No

Prefer not to answer

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 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)?

Yes (proceed to next question)

No (skip to Section 5)

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)

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

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?

Yes No

Prefer not to answer

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 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)

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?

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?

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?

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.