MCBS COVID-19 Rapid Response Supplement Questionnaire
Var Name |
Question Text/Description |
Response Options |
Routing |
QUEXLANG |
PLEASE SELECT THE LANGUAGE IN WHICH YOU WOULD LIKE TO CONDUCT THE INTERVIEW.
|
(01) ENGLISH (02) SPANISH
|
NEXT QUESTION |
INTRO1 |
Thank you for agreeing to participate in this short survey about your experiences during the coronavirus outbreak. |
(01) CONTINUE |
NEXT QUESTION |
ATDOOR |
All survey information will be kept private to the extent permitted by law, as prescribed by the Privacy Act of 1974. Medicare benefits will not be affected in any way by survey responses or participation.
REFER TO THE "AT-THE-DOOR" SHEET IF THE RESPONDENT NEEDS ADDITIONAL REASSURANCE |
(01) CONTINUE |
NEXT QUESTION |
VERIFYSP |
VERIFY THE SP’S NAME. IS THE SP’S NAME CORRECT AND COMPLETE?
FIRST NAME: (SP'S FIRST NAME) MIDDLE INITIAL: (SP'S MIDDLE INITIAL) LAST NAME: (SP'S LAST NAME) |
(01) YES (02) NO |
(01) SPAISTATUS (02) ROSTNAME |
ROSTNAME |
MAKE ALL NECESSARY CORRECTIONS TO THE SP'S NAME.
FIRST NAME:
MIDDILE INITIAL:
LAST NAME |
(01) CONTINUE |
SPAISTATUS |
SPAISTATUS |
PLEASE INDICATE THE SP’S CURRENT STATUS. IF THE CASE IS A PROXY INTERVIEW AND YOU HAVEN’T TALKED ABOUT THE SP’S VITAL STATUS, PROBE AT THIS TIME ABOUT WHETHER THE SP IS ALIVE OR DECEASED AND WHERE THE SP IS LOCATED.
WHEN WE REFER TO INSTITUTIONALIZED, WE ARE REFERRING TO THE MCBS DEFINITION OF A FACILITY. PLEASE REMEMBER THAT HOSPITALS ARE NOT FACILITIES UNDER THE MCBS DEFINITION SO SPS IN HOSPITALS SHOULD NOT BE CONSIDERED TO BE INSTITUTIONALIZED BELOW.
FOR THE FULL MCBS DEFINITION OF A FACILITY, SEE THE “MCBS FACILITY DEFINITION” REFERENCE CARD.
IS THE SP CURRENTLY: |
|
|
INTHANK |
THIS CASE IS NOT ELIGIBLE FOR THE MCBS CORONAVIRUS SURVEY.
THANK THE RESPONDENT THEN BREAKOFF AND CODE THE CASE IN NORCSUITE USING THE APPROPRIATE DISPOSITION. |
|
|
SPPROXY |
WILL THIS INTERVIEW BE CONDUCTED WITH THE SAMPLE PERSON OR WITH A PROXY? |
(01) SAMPLE PERSON (02) PROXY |
(01) INTRO2 (02) ROSTREL |
ROSTREL |
[What is the relationship to (SP)?] |
(02) SPOUSE (03) SON (04) DAUGHTER (05) BROTHER (06) SISTER (07) FATHER (08) MOTHER (09) SON-IN-LAW (10) DAUGHTER-IN-LAW (11) GRANDSON (12) GRANDDAUGHTER (13) NEPHEW (14) NIECE (51) FRIEND/NEIGHBOR (52) BOARDER (53) NURSE/NURSE'S AIDE (54) LEGAL/FINANCIAL OFFICER (55) GUARDIAN (56) PARTNER (57) ROOMMATE (91) OTHER (-8) DON'T KNOW (-9) REFUSED |
NEXT QUESTION |
WHYPROXY |
WHAT IS THE MAIN REASON THAT A PROXY RESPONDENT NECESSARY? |
(01) SP NOT CAPABLE PHYSICALLY/SICK/BLIND/CAN’T SPEAK/HEAR (02) SP NOT CAPABLE MENTALLY/POOR MEMORY/PSYCHIATRIC DISORDER (03) SP UNABLE TO PROVIDE INFORMATION REGARDING MEDICAL RECORDS (04) SP IN HOSPITAL (05) LANGUAGE PROBLEM (08) SP NOT AVAILABLE THIS ROUND (09) AUTHORIZED PROXY MUST ANSWER QUESTIONS FOR SP (CODE REASON WHY) (91) OTHER |
INTRO2 |
INTRO2 |
The first set of questions are about your experiences using health care services. |
|
NEXT QUESTION |
PLACEPAR
|
Is there a particular doctor or other health professional, or a clinic you usually go to when you are sick or for advice about your health? |
(01) YES (02) NO (-8) DON'T KNOW (-9) REFUSED
|
(01) PLACEKIND (02) COMPUTER (-8) COMPUTER (-9) COMPUTER
|
PLACEKIND |
What kind of place do you usually go to when you are sick or for advice about your health -- is that a managed care plan or HMO center, a clinic, a doctor or other health professional's office, a hospital, or some other place?
IF CLINIC, ASK: Is it a hospital outpatient clinic, or some other kind of clinic? IF SOME OTHER PLACE, ASK: Where is this? |
CODE BASED ON THE RESPONSE R GIVES:
(01) DOCTOR'S OFFICE OR GROUP PRACTICE (02) MEDICAL CLINIC (03) MANAGED CARE PLAN CENTER/HMO (04) NEIGHBORHOOD/FAMILY HEALTH CENTER (05) FREESTANDING SURGICAL CENTER (06) RURAL HEALTH CLINIC (07) COMPANY CLINIC (08) OTHER CLINIC (09) WALK-IN URGENT CENTER (10) DOCTOR COMES TO SP'S HOME (11) HOSPITAL EMERGENCY ROOM (12) HOSPITAL OUTPATIENT DEPARTMENT/CLINIC (13) VA FACILITY (14) MENTAL HEALTH CENTER (91) OTHER (-8) DON'T KNOW (-9) REFUSED
|
NEXT QUESTION |
TELMED
|
Does your usual provider offer telephone or video appointments, so that you don't need to physically visit their office or facility?
IF NEEDED: Did your provider offer to talk to you about your symptoms over the phone or video so that you wouldn’t have to visit their office or facility?
|
(01) YES (02) NO (-8) DON'T KNOW (-9) REFUSED |
(01) NEXT QUESTION (02) TELMEDNEW (-8) TELMEDNEW (-9) TELMEDNEW |
TELMEDTYPE1 |
Do they offer telephone appointments, video appointments, or both? |
(01) TELEPHONE (02) VIDEO (03) BOTH (-8) DON’T KNOW (-9) REFUSED |
NEXT QUESTION |
TELMEDNEW |
Did your usual provider offer telephone or video appointments before the Coronavirus outbreak?
|
(01) YES (02) NO (-8) DON'T KNOW (-9) REFUSED |
(01) NEXT QUESTION (02) TELMEDNEW2 (-8) TELMEDNEW2 (-9) TELMEDNEW2 |
TELMEDTYPE2 |
Did they offer telephone appointments, video appointments, or both? |
(01) TELEPHONE (02) VIDEO (03) BOTH (-8) DON’T KNOW (-9) REFUSED |
NEXT QUESTION |
TELMEDNEW2 |
Did your usual provider offer you a telephone or video appointment to replace a regularly scheduled appointment during the Coronavirus outbreak? |
(01) YES (02) NO (-8) DON'T KNOW (-9) REFUSED |
(01) NEXT QUESTION (02) COMPUTER (-8) COMPUTER (-9) COMPUTER |
TELMEDTYPE3 |
Did they offer telephone appointments, video appointments, or both? |
(01) TELEPHONE (02) VIDEO (03) BOTH (-8) DON’T KNOW (-9) REFUSED |
NEXT QUESTION |
COMPUTER |
The next questions ask about use of the internet.
Do you own or use any of the following types of computers? Please tell me yes or no for each item I list.
|
(01) YES (02) NO (-8) DON'T KNOW (-9) REFUSED |
NEXT QUESTION |
INTERNET |
Do you have access to the internet? |
(01) YES (02) NO (-8) DON'T KNOW (-9) REFUSED |
NEXT QUESTION |
AUDIOVIDEO |
Have you ever participated in video or voice calls or conferencing over the Internet, such as with Skype or FaceTime?
IF NEEDED: Do you participate in video or voice calls or conferencing? |
(01) YES (02) NO (-8) DON'T KNOW (-9) REFUSED |
NEXT QUESTION |
COVID_CARE |
Now I’d like to ask about care you were unable to get because of the coronavirus pandemic.
At any time since the beginning of the Coronavirus outbreak, did you need medical care for something other than coronavirus, but not get it because of the coronavirus outbreak?
IF NEEDED: Have you had any medical appointments rescheduled because of the coronavirus outbreak? Or, have you needed a medical appointment but were unable to schedule one because of the coronavirus outbreak? |
(01) YES (02) NO (-8) DON'T KNOW (-9) REFUSED |
(01) NOCARTYP (02) AUTOINTRO (-8) AUTOINTRO (-9) AUTOINTRO |
NOCARTYP
|
Were you unable to get any of the following types of care because of the outbreak?
READ EACH ITEM AND RECORD YES/NO RESPONSE:
IF NEEDED: Please include preventative tests like mammograms and colonoscopies as “Diagnostic or Medical Screening Test”
|
(01) YES (02) NO (03) NOT APPLICABLE (-8) DON'T KNOW (-9) REFUSED |
IF YES SELECTED FOR ANY ITEMS, GO TO NOCARDIR.
FOR EACH TYPE OF CARE SELECTED AT NOCARTYP, ASK NOCARWHYR AND THE APPLICABLE FOLLOW-UP
IF NO TYPES SELECTED AT NOCARETYP, SKIP TO AUTOINTRO |
NOCARDIR |
Regarding your [NOCARTYP], did your medical provider make this decision or did you? IF NEEDED: If you had contact with your medical provider about re-scheduling or canceling an appointment for care, but they gave you the option to keep your originally-scheduled appointment, please answer that you decided not to get care. |
(01) PROVIDER DECIDED (02) R DECIDED (03) BOTH (-8) DON'T KNOW (-9) REFUSED |
(-8) AUTOINTRO (-9) AUTOINTRO
|
REASONMD |
Did your medical provider give you a reason why they needed to reschedule? |
(01) YES (02) NO (-8) DON'T KNOW (-9) REFUSED |
(01) NOCARWHYMD
(02), (-8), (-9): IF NOCARDIR= “BOTH” GO TO NOCARWHYR
ELSE, IF MORE THAN ONE TYPE OF CARE SELECTED AT NOCARTYP, GO BACK TO NOCARDIR AND ASK ABOUT THE NEXT CONDITION.
|
NOCARWHYMD |
What reasons were you given for this decision?
READ EACH ITEM AND RECORD YES/NO RESPONSE:
(01) Was the medical office closed? (02) Was priority given to other types of appointments? (03) Did the medical office reduce available appointments? (04) Was there some other reason? IF ANOTHER REASON: What was that reason?
|
(01) YES (02) NO (-8) DON'T KNOW (-9) REFUSED
|
IF NOCARDIR= “BOTH” GO TO NOCARWHYR
ELSE, IF MORE THAN ONE TYPE OF CARE SELECTED AT NOCARTYP, GO BACK TO NOCARDIR AND ASK ABOUT THE NEXT CONDITION.
|
NOCARWHYR
|
What reasons did you have for your decision?
READ EACH ITEM AND RECORD YES/NO RESPONSE:
(01) Did you have no access to transportation? (02) Did you not want to leave your house? (03) Did you not want to risk being at a medical facility? (04) Was there some other reason? IF ANOTHER REASON: What was that reason? |
(01) YES (02) NO (-8) DON'T KNOW (-9) REFUSED
|
IF MORE THAN ONE TYPE OF CARE WERE SELECTED AT NOCARDIR, GO TO COCARDIR AND ASK ABOUT NEXT TYPE.
OTHERWISE, GO TO NEXT QUESTION.
|
AUTOINTRO |
The next questions are about health conditions you may have. |
(01) CONTINUE |
NEXT QUESTION |
AUTOEV1 |
Has a doctor or other health professional ever told you that you had . . .
…a weakened immune system caused by a chronic illness?
[IF NEEDED: Some diseases cause you to become immunocompromised or immunodeficient, which means your body can’t fight off infections as well. Examples of diseases like this include multiple sclerosis, rheumatoid arthritis, lupus, HIV/AIDS, and many others.]
|
(01) YES (02) NO (-8) DON'T KNOW (-9) REFUSED |
NEXT QUESTION |
AUTOEV2 |
[Has a doctor or other health professional ever told you that you had . . .]
…a weakened immune system caused by medicines or treatment for a chronic illness?
[IF NEEDED: People with certain health conditions may need to take medications with side effects that can weaken their immune system.]
|
(01) YES (02) NO (-8) DON'T KNOW (-9) REFUSED |
NEXT QUESTION |
COVIDINTRO
|
Now I want to ask you some questions about the recent coronavirus, also known as COVID-19. |
CONTINUE |
NEXT QUESTION |
SYMPTOMS |
Which, if any, of the following symptoms have you had since the coronavirus outbreak started?
READ EACH ITEM AND RECORD YES/NO RESPONSE:
|
(01) YES (02) NO (-8) DON'T KNOW (-9) REFUSED |
NEXT QUESTION |
SUSPECT |
Do you suspect that you have ever had the Coronavirus or Covid-19? |
(01) YES (02) NO (-8) DON'T KNOW (-9) REFUSED |
(01) NEXT QUESTION (02) COVIDEV (-8) COVIDEV (-9) COVIDEV |
SUSPECTWHY |
What symptoms did you have that made you suspect you had the coronavirus? |
[INTERVIEWER CODE BASED ON VERBATIM RESPONSE FROM RESPONDENT]
(-8) DON'T KNOW |
NEXT QUESTION |
COVIDEV |
Has a doctor or other health professional ever told you that you have or likely had Coronavirus or COVID-19?
[IF NEEDED: A doctor might make this diagnosis based on a test for COVID-19 or based on symptoms you have.]
|
(01) YES (02) NO
|
NEXT QUESTION |
WANTTEST |
Have you ever asked a doctor or medical professional for a Coronavirus test? |
(01) YES (02) NO (-8) DON'T KNOW (-9) REFUSED |
NEXT QUESTION |
REFUSTEST |
Have you ever been refused a coronavirus test when you wanted one? |
(01) YES, HAVE BEEN (02) NO, HAVE NOT BEEN REFUSED TEST (-8) DON'T KNOW (-9) REFUSED |
NEXT QUESTION |
COVIDPOS |
Have you ever been tested for Coronavirus or COVID-19?
[IF NEEDED: For example, the test can be done by swabbing your nose.] |
(01) YES (02) NO (-8) DON'T KNOW (-9) REFUSED |
(01) RESULTS (02) BOX A (-8) BOX A (-9) BOX A |
RESULTS |
What was the result of the test? |
(01) THE TEST SHOWED R HAD COVID-19 (02) THE TEST SHOWED R DID NOT HAVE COVID-19
(-8) DON’T KNOW (-9) REFUSED
|
BOX A |
BOX A |
IF COVIDEV=YES OR SUSPECT=YES OR RESULTS=01 THEN GO TO COVIDCAR.
OTHERWISE GO TO COVIDEVHH. |
|
|
COVIDCAR |
Have you been treated for the coronavirus or COVID-19?
IF NEEDED: Treatment for coronavirus might include prescribing medication to help manage symptoms, hospitalization, or the use of oxygen or a ventilator. |
(01) YES (02) NO (-8) DON'T KNOW (-9) REFUSED |
(01) COVID_HOSP (02) COVIDCARNO (-9) COVID_HOSP (-9) COVID_HOSP |
COVIDCARNO |
Why did you not get this treatment?
READ EACH ITEM AND RECORD YES/NO RESPONSE:
IF ANOTHER REASON: What was that reason?
|
(01) YES (02) NO (-8) DON'T KNOW (-9) REFUSED |
COVIDEVHH |
COVID_HOSP |
Have you been hospitalized overnight for coronavirus?
[IF NEEDED: This could include visiting the emergency room or being admitted to the hospital.] |
(01) YES (02) NO (-8) DON'T KNOW (-9) REFUSED |
NEXT QUESTION |
COVIDEVHH |
Has a doctor or other health professional ever told anyone living in your household that they have or likely have Coronavirus or COVID-19?
[IF NEEDED: A doctor might make this diagnosis based on a test for COVID-19 or based on symptoms they have.] |
(01) YES (02) NO (03) R LIVES ALONE (-8) DON'T KNOW (-9) REFUSED |
(01) HHSYMPTOMS (02) HHSYMPTOMS (03) PREVENT (-8) HHSYMPTOMS (-9) HHSYMPTOMS |
HHSYMPTOMS |
Since the beginning of the coronavirus outbreak, has anyone living in your household had a fever, dry cough and shortness of breath? |
(01) YES (02) NO (-8) DON'T KNOW (-9) REFUSED |
NEXT QUESTION |
PREVENT
|
Have you done any of the following in response to the outbreak of the new coronavirus?
READ EACH ITEM AND RECORD YES/NO RESPONSE:
|
(01) YES (02) NO (03) UNABLE DUE TO SHORTAGES (04) NOT APPLICABLE (-8) DON'T KNOW (-9) REFUSED |
NEXT QUESTION |
BVI5 |
What sources do you rely on for information about the coronavirus? For each source I read, please tell me yes or no.
READ EACH ITEM AND RECORD YES/NO RESPONSE:
(01) Traditional news sources, including on TV, radio, websites, and newspapers (02) Social media (03) Comments or guidance from government officials (04) Other webpages/internet (05) Friends or family members (06) Health care providers
|
(01) YES (02) NO (-8) DON'T KNOW (-9) REFUSED
|
IF AT LEAST ONE RESPONSE IS YES, GO TO BVIMOST
ELSE GO TO CDREC1. |
BVIMOST |
You said you rely on [DISPLAY ALL ITEMS FOR WHICH RESPONSE TO BVI5 WAS YES] for information about the coronavirus. Which of these sources do you rely on most?
|
DISPLAY ALL ITEMS FOR WHICH RESPONSE TO BVI5 WAS “YES”.
(-8) DON'T KNOW (-9) REFUSED |
NEXT QUESTION |
CDCREC1
|
As far as you know, have public health experts recommended the following things as a way to help slow the spread of coronavirus, or not?
a. Frequent hand washing |
(-8) DON’T KNOW (-9) REFUSED |
NEXT QUESTION |
CDCREC2 |
b. Healthy people wearing facemasks in public
[IF NEEDED: As far as you know, have public health experts recommended this as a way to help slow the spread of coronavirus?] |
(01) YES, RECOMMENDED (02) NO, NOT RECOMMENDED (-8) DON’T KNOW (-9) REFUSED |
NEXT QUESTION |
CDCREC3 |
c. Avoiding gatherings with large numbers of people
[IF NEEDED: As far as you know, have public health experts recommended this as a way to help slow the spread of coronavirus?]
|
(01) YES, RECOMMENDED (02) NO, NOT RECOMMENDED (-8) DON’T KNOW (-9) REFUSED |
NEXT QUESTION |
CDCREC4 |
d. Staying home except for essential activities such as grocery shopping or medical care (shelter in place)
[IF NEEDED: As far as you know, have public health experts recommended this as a way to help slow the spread of coronavirus?] |
(01) YES, RECOMMENDED (02) NO, NOT RECOMMENDED (-8) DON’T KNOW (-9) REFUSED |
NEXT QUESTION |
CDCREC5 |
d. Seeking medical attention if you are having trouble breathing
[IF NEEDED: As far as you know, have public health experts recommended this as a way to help slow the spread of coronavirus?] |
(01) YES, RECOMMENDED (02) NO, NOT RECOMMENDED (-8) DON’T KNOW (-9) REFUSED |
NEXT QUESTION |
DISR_HOUSE |
Since the coronavirus outbreak began, have you been able, unable, or have not needed…
To pay rent or your mortgage?
IF THE RESPONDENT OWNS THEIR HOME OUTRIGHT SO DOESN’T NEED TO PAY RENT OR MORTGAGE, SELECT “HAVE NOT NEEDED”. |
(01) ABLE (02) UNABLE (03) HAVE NOT NEEDED (-8) DON’T KNOW (-9) REFUSED |
NEXT QUESTION |
DISR_MED |
[Since the coronavirus outbreak began, have you been able, unable, or have not needed…]
To get medications? |
(01) ABLE (02) UNABLE (03) HAVE NOT NEEDED (-8) DON’T KNOW (-9) REFUSED |
NEXT QUESTION |
DISR_DOC |
[Since the coronavirus outbreak began, have you been able, unable, or have not needed…]
To get a doctor’s appointment or some other kind of healthcare? |
(01) ABLE (02) UNABLE (03) HAVE NOT NEEDED (-8) DON’T KNOW (-9) REFUSED |
NEXT QUESTION |
DISR_FOOD |
[Since the coronavirus outbreak began, have you been able, unable, or have not needed…]
To get the food you want? |
(01) ABLE (02) UNABLE (03) HAVE NOT NEEDED (-8) DON’T KNOW (-9) REFUSED |
NEXT QUESTION |
DISR_SUP |
[Since the coronavirus outbreak began, have you been able, unable, or have not needed…]
To get household supplies, such as toilet paper?
IF RESPONDENT WANTED TO GET HOUSEHOLD SUPPLIES BUT WAS NOT ABLE TO BECAUSE OF SUPPLY SHORTAGES, SELECT “UNABLE”. |
(01) ABLE (02) UNABLE (03) HAVE NOT NEEDED (-8) DON’T KNOW (-9) REFUSED
|
NEXT QUESTION |
FEEL_FINC |
Since the coronavirus outbreak began…
have you felt more financially secure, less financially secure, or about the same? |
(01) MORE FINANCIALLY SECURE (02) LESS FINANCIALLY SECURE (03) ABOUT THE SAME (-8) DON’T KNOW (-9) REFUSED |
NEXT QUESTION |
FEEL_ANX |
[Since the coronavirus outbreak began…]
have you felt more stressed or anxious, less stressed or anxious, or about the same?
|
(01) MORE STRESSED OR ANXIOUS (02) LESS STRESSED OR ANXIOUS (03) ABOUT THE SAME (-8) DON’T KNOW (-9) REFUSED |
NEXT QUESTION |
FEEL_DEP |
[Since the coronavirus outbreak began…]
have you felt more lonely or sad, less lonely or sad, or about the same? |
(01) MORE LONELY OR SAD (02) LESS LONELY OR SAD (03) ABOUT THE SAME (-8) DON’T KNOW (-9) REFUSED |
NEXT QUESTION |
FEEL_SOC
|
[Since the coronavirus outbreak began…]
have you felt more socially connected to family and friends, less socially connected to family and friends, or about the same? |
(01) MORE SOCIALLY CONNECTED (02) LESS SOCIALLY CONNECTED (03) ABOUT THE SAME (-8) DON’T KNOW (-9) REFUSED |
NEXT QUESTION |
THANKYOU |
Thank you for participating in this important survey.
AFTER THANKING THE RESPONDENT, YOU MAY PROVIDE THEM WITH AN UPDATE ON WHEN YOU WILL NEXT BE IN CONTACT WITH THEM.
HANG UP THE PHONE AND THEN PROCEED TO THE IRQ QUESTIONS |
(01) CONTINUE |
NEXT QUESTION |
BUNDLE |
WAS THIS INTERVIEW CONDUCTED ON THE SAME DAY AS THE CURRENT ROUND INTERVIEW? |
(01) YES (02) NO |
NEXT QUESTION |
RRECHELP |
DID THE [SP/PROXY] RECEIVE ANY HELP IN ANSWERING THE QUESTIONS? |
(01) YES (02) NO |
NEXT QUESTION |
RINFOSAT |
DO YOU FEEL THAT THE INFORMATION PROVIDED BY THE RESPONDENT WAS SATISFACTORY? |
(01) YES (02) NO |
END |
| File Type | application/vnd.openxmlformats-officedocument.wordprocessingml.document |
| Author | Samantha Rosner |
| File Modified | 0000-00-00 |
| File Created | 2021-01-11 |