Form 0923-22BJ Adult Follow-up Survey

Protocol, PFAS/viral infection, v1.0

Last Revised: August 23, 2021

Survey Reading Level: 7.3

Appendix C – Follow-up Survey (paper) – Adult

Form Approved

OMB No. 0923-xxxx

Exp. Date xx/xx/201x

xx/xx/20xx201x

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 Survey

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-xxxx).

[Insert PDF of REDCap version of the adult survey. In order to ensure consistency between participants responding via REDCap and those responding via paper, the REDCap version of the survey will be printed out as the paper version].

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FOR OFFICE USE ONLY:

STUDY ID: __________________________________