Form 1 COVID Screening Statement

COVID Screening Statement

INTERVIEWER: The COVID statement should be read to the respondent prior to entering a household.

After explaining why you are there and gaining cooperation to conduct the interview, explain to the respondent that if none of the following statements are true you can proceed with the interview but if any of the statements are true, you will need to re-schedule the interview to another time or conduct the interview outside (unless it is the respondent exhibiting symptoms or self-quarantining).

• Anyone in the household, including the respondent, is currently ill or having flu-like or COVID-19 symptoms (including exhibiting respiratory symptoms or a fever of 100.4 or higher) or anyone in the household, including the respondent, has been ill or had such symptoms in the past 14 days.

• A healthcare provider has informed anyone in the household, including the respondent, that they are suspected or confirmed to have COVID-19.

• Anyone in the household, including the respondent, been told by a healthcare provider to self-quarantine due to COVID-19 exposure.

• Anyone in the household, including the respondent, been in close contact with a non-household member who has been informed by a healthcare provider that they are suspected or confirmed to have COVID-19 or who has exhibited flu-like or COVID-19 symptoms.

• Anyone in the household, including the respondent traveled internationally within the past 14 days.