Respondent information

We are collecting information about an unusual cluster of serious illnesses among people who have lived in North St. Louis County. This survey started as a labor of love for those of us who have lost loved ones, and is an important tool to help us understand what is happening. We respect the sensitivity of what you are sharing and encourage you to participate in the Facebook website for more support. Please know that we extend our heartfelt sympathies to all of those (including us!) who have been impacted.

Your participation is voluntary. We will use the information to update the map of illnesses, and may make information available to others (such as the Centers for Disease Control) who are also studying the situation.

If you would like to provide information for MULTIPLE INDIVIDUALS, please fill out one survey for EACH PERSON. This will greatly help us in our data collection.

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* 1. What is your name?

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* 2. What is your email address?

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* 3. Are you reporting information about yourself, or someone else? If you would like to report about yourself AND someone else, please start with YOURSELF.