Form Attachment A – COV Attachment A – COV Attachment A – COVID-19 Questions

Attachment A

Section: __CV______

Item #: __CV10______ Blaise Name (new variable name): Click here to enter text.

Type Class: __Enumerated______

Answer Type: __TYESNO______

Help Available: __Click here to enter text.______

Show Card: __Click here to enter text.______

Look Up File: __Click here to enter text.______

Write To:

Parent Variable	Variable Name	Variable Label

Context Header:

Question Text:

The following questions are about the impacts of the coronavirus (COVID-19) pandemic on the use of health care.

For this question, do not include dental care or prescription medicines. Between March 2020 and today, {{have you/has {PERSON}} delayed seeking any medical care/has medical care been delayed for anyone in the household} because of the coronavirus pandemic?

Responses:

YES…………………….1 CV20

NO…………………….. 2 CV30

REFUSED……………...RF CV30

DON’T KNOW………...DK CV30

Programmer Instructions:

If coded ‘1’ (YES) and a MULTI-PERSON RU, continue with CV20.

If coded ‘1’ (YES) and a SINGLE-PERSON RU, automatically code person at CV20, and go to

CV30.

Display Instructions:

Display ‘{have you/has {PERSON}} delayed seeking medical care’ if SINGLE-PERSON RU.

Otherwise, display ‘has medical care been delayed for anyone in the household’.

Display ‘have you’ if respondent is RU member. Otherwise, display ‘has {PERSON}’.

Testing/Editing Notes:

Section: __CV______

Item #: __CV20______ Blaise Name (new variable name): Click here to enter text.

Type Class: __Enumerated______

Answer Type: __TFIRSTMIDLASTNA______

Help Available: __Click here to enter text.______

Show Card: __Click here to enter text.______

Look Up File: __Click here to enter text.______

Write To:

Parent Variable	Variable Name	Variable Label

Context Header:

Question Text:

Who was that?

PROBE: Did anyone else delay seeking any medical care because of the coronavirus pandemic?

ENTER ALL THAT APPLY.

Responses:

{FIRST NAME [MIDDLE NAME] LAST NAME}………..1

{FIRST NAME [MIDDLE NAME] LAST NAME}………..2

{FIRST NAME [MIDDLE NAME] LAST NAME}………..3

{FIRST NAME [MIDDLE NAME] LAST NAME}………..4

{FIRST NAME [MIDDLE NAME] LAST NAME}………..N

Programmer Instructions:

Go to CV30.

Display Instructions:

Roster 2 - no add/edit/delete

Roster definition:

This item displays RU members roster for selection. Display RU member’s first, middle, and

last name (Person.FullName).

Roster filter:

No filter; display all.

Testing/Editing Notes:

Section: __CV______

Item #: __CV30______ Blaise Name (new variable name): Click here to enter text.

Type Class: __Enumerated______

Answer Type: __TYESNO______

Help Available: __Click here to enter text.______

Show Card: __Click here to enter text.______

Look Up File: __Click here to enter text.______

Write To:

Parent Variable	Variable Name	Variable Label

Context Header:

Question Text:

Now please think only about dental care. Between March 2020 and today, {{have you/has {PERSON}} {have you/has {PERSON}} delayed seeking dental care (including check-ups)/has dental care (including check-ups) been delayed for anyone in the household} because of the coronavirus pandemic?

Responses:

YES…………………………1

NO…………………………..2 CV50

REFUSED…………………..RF CV50

DON’T KNOW……………..DK CV50

Programmer Instructions:

If coded ‘1’ (YES) and a MULTI-PERSON RU, continue with CV40.

If coded ‘1’ (YES) and a SINGLE-PERSON RU, automatically code person at CV40, and go to

CV50.

Display Instructions:

Display ‘{have you/has {PERSON}} delayed seeking dental care (including check-ups)’ if

SINGLE-PERSON RU. Otherwise, display ‘has dental care (including check-ups) been delayed for anyone in the household’.

Display ‘have you’ if respondent is RU member. Otherwise, display ‘has {PERSON}’.

Testing/Editing Notes:

Section: __CV______

Item #: __CV40______ Blaise Name (new variable name): Click here to enter text.

Type Class: __TYESNO______

Answer Type: __TFIRSTMIDLASTNA______

Help Available: __Click here to enter text.______

Show Card: __Click here to enter text.______

Look Up File: __Click here to enter text.______

Write To:

Parent Variable	Variable Name	Variable Label

Context Header:

Question Text:

Who was that?

PROBE: Did anyone else delay seeking dental care (including check-ups) because of the coronavirus pandemic?

Responses:

{FIRST NAME [MIDDLE NAME] LAST NAME}………..1

{FIRST NAME [MIDDLE NAME] LAST NAME}………..2

{FIRST NAME [MIDDLE NAME] LAST NAME}………..3

{FIRST NAME [MIDDLE NAME] LAST NAME}………..4

{FIRST NAME [MIDDLE NAME] LAST NAME}………..N

Programmer Instructions:

Go to CV50.

Display Instructions:

Roster 2 - no add/edit/delete

Roster definition:

This item displays RU members roster for selection. Display RU member’s first, middle, and

last name

(Person.FullName).

Roster filter:

No filter; display all.

Testing/Editing Notes:

Section: __CV______

Item #: __CV50______ Blaise Name (new variable name): Click here to enter text.

Type Class: __Enumerated______

Answer Type: __TYESNO______

Help Available: __Click here to enter text.______

Show Card: __Click here to enter text.______

Look Up File: __Click here to enter text.______

Write To:

Parent Variable	Variable Name	Variable Label

Context Header:

Question Text:

Now please think only about prescription medicines. Between March 2020 and today, {{have you/has {PERSON}} delayed getting prescription medicines/have prescription medicines been delayed for anyone in the household} because of the coronavirus pandemic?

Responses:

YES………………………1

NO………………………..2 Box 10

REFUSED………………..RF Box 10

DON’T KNOW…………..DK Box 10

Programmer Instructions:

If coded ‘1’ (YES) and a MULTI-PERSON RU, continue with CV60.

If coded ‘1’ (YES) and a SINGLE-PERSON RU, automatically code person at CV60 and go to

Box 10.

Display Instructions:

Display ‘{have you/has {PERSON}} delayed getting prescription medicines’ if SINGLE-PERSON RU. Otherwise, display ‘have prescription medicines been delayed for anyone in the

household’.

Display ‘have you’ if respondent is RU member. Otherwise, display ‘has {PERSON}’.

Testing/Editing Notes:

Section: __CV______

Item #: __CV60______ Blaise Name (new variable name): Click here to enter text.

Type Class: __Enumerated______

Answer Type: __TFIRSTMIDLASTNA______

Help Available: __Click here to enter text.______

Show Card: __Click here to enter text.______

Look Up File: __Click here to enter text.______

Write To:

Parent Variable	Variable Name	Variable Label

Context Header:

Question Text:

Who was that?

PROBE: Did anyone else delay getting prescription medicines because of the coronavirus pandemic?

ENTER ALL THAT APPLY.

Responses:

{FIRST NAME [MIDDLE NAME] LAST NAME}………..1

{FIRST NAME [MIDDLE NAME] LAST NAME}………..2

{FIRST NAME [MIDDLE NAME] LAST NAME}………..3

{FIRST NAME [MIDDLE NAME] LAST NAME}………..4

{FIRST NAME [MIDDLE NAME] LAST NAME}………..N

Programmer Instructions:

Go to Box 10.

Display Instructions:

Roster 2 - no add/edit/delete

Roster definition:

This item displays RU members roster for selection. Display RU member’s first, middle, and

last name

(Person.FullName).

Roster filter:

No filter; display all.

Testing/Editing Notes:

Section: __CV______

Item #: __Box_10______ Blaise Name (new variable name): Click here to enter text.

Type Class: __Click here to enter text.______

Answer Type: __Click here to enter text.______

Help Available: __Click here to enter text.______

Show Card: __Click here to enter text.______

Look Up File: __Click here to enter text.______

Write To:

Parent Variable	Variable Name	Variable Label

Context Header:

Question Text:

GO TO NEXT QUESTIONNAIRE SECTION (EMPLOYMENT).

Responses:

Programmer Instructions:

Display Instructions:

Testing/Editing Notes: