Variable Name
|
Question Text
|
Response Options
|
Routing
|
Facility-Level Questions
|
|
Thank you for agreeing to participate in this short survey about
(FACILITYS’ NAME) experiences during the coronavirus
pandemic, also known as
COVID-19 or SARS-CoV-2.
|
(01) CONTINUE
|
NEXT QUESTION
|
SUSINTRO
|
As of today, are any in-person services currently
suspended, inside or outside of (FACILITY NAME), due to the
coronavirus pandemic?
[IF NEEDED:
Please include only in-person services.]
[IF NEEDED: Suspension of in-person
services means these services are not currently being provided
in-person.]
|
NO,
NOT SUSPENDED
YES,
SUSPENDED
(-8) DON’T KNOW
(-9) REFUSED
|
(00) TELINTRO
(01) NEXT QUESTION
(-8) TELINTRO
(-9) TELINTRO
|
OUTDRSUS
|
[As of today] are in-person primary care visits with a
doctor or other health professional outside this facility
currently suspended due to the coronavirus pandemic?
[IF NEEDED: Primary care visits are
for treating common medical conditions and may be for regular
check-ups.]
|
NO,
NOT SUSPENDED
YES,
SUSPENDED
NOT
APPLICABLE
(-8) DON’T KNOW
(-9) REFUSED
|
NEXT QUESTION
|
OUTDRSP
|
[As of today] are in-person specialty care visits with a
doctor or other health professional outside this facility
currently suspended due to the coronavirus pandemic?
[IF NEEDED: Specialty care visits
may be for more complex health issues, such as chronic
conditions.]
|
(00) NO, NOT SUSPENDED
(01) YES, SUSPENDED
NOT
APPLICABLE
(-8) DON’T KNOW
(-9) REFUSED
|
NEXT QUESTION
|
INDRSUSP
|
[As of today] are in-person primary care visits with a
doctor or other health professional inside this facility
currently suspended due to the coronavirus pandemic?
[IF NEEDED: Primary care visits are
for treating common medical conditions and may be for regular
check-ups.]
|
NO,
NOT SUSPENDED
YES,
SUSPENDED
NOT
APPLICABLE
(-8) DON’T KNOW
(-9) REFUSED
|
NEXT QUESTION
|
INDRSPEC
|
[As of today] are in-person specialty care visits with a
doctor or other health professional inside this facility
currently suspended due to the coronavirus pandemic?
[IF NEEDED: Specialty care visits may be for more complex
health issues, such as chronic conditions.]
|
(00) NO, NOT SUSPENDED
(01) YES, SUSPENDED
NOT
APPLICABLE
(-8) DON’T KNOW
(-9) REFUSED
|
NEXT QUESTION
|
OTHSUSPE
|
[As of today] are any of the following in-person services, both
inside and outside this facility, currently suspended due
to the coronavirus pandemic?
Ask YES/NO for each:
Dental
visits
Psychiatrist
or other mental health professional visits
Podiatrist
visits
Educational
or habilitational services
Any
other types of services
|
(00) NO, NOT SUSPENDED
YES,
SUSPENDED
NOT
APPLICABLE
(-8) DON’T KNOW
(-9) REFUSED
|
NEXT QUESTION
|
TELINTRO
|
Did (FACILITY NAME) offer any services through telehealth before
the coronavirus pandemic?
|
NO
YES
(-8) DON’T KNOW
(-9) REFUSED
|
(00) TELCOVID
(01) NEXT QUESTION
(-8) TELCOVID
(-9) TELCOVID
|
OUTDRTEL
|
Were doctor or other health professional visits outside
this facility offered through telehealth before the
coronavirus pandemic? Please include outside visits for both
primary and specialty care.
VISITS SHOULD INCLUDE BOTH PRIMARY AND SPECIALTY CARE. IF
SERVICES WERE OFFERED THROUGH TELEHEALTH FOR EITHER PRIMARY OR
SPECIALITY CARE OUTSIDE THE FACILITY ANSWER “YES”.
|
(00) NO
(01) YES
(02) NOT APPLICABLE
(-8) DON’T KNOW
(-9) REFUSED
|
NEXT QUESTION
|
INDRTELE
|
Were doctor or other health professional visits inside this
facility offered through telehealth before the coronavirus
pandemic?
VISITS SHOULD INCLUDE BOTH PRIMARY AND SPECIALTY CARE. IF
SERVICES WERE OFFERED THROUGH TELEHEALTH FOR EITHER PRIMARY OR
SPECIALITY CARE INSIDE THE FACILITY ANSWER “YES”.
|
(00) NO
(01) YES
(02) NOT APPLICABLE
(-8) DON’T KNOW
(-9) REFUSED
|
NEXT QUESTION
|
TELMED1
|
Which of the following services, both inside and outside this
facility, were offered through telehealth before the
coronavirus pandemic?
Ask YES/NO for each:
Dental
visits
Psychiatrist
or other mental health professional visits
Podiatrist
visits
Educational
or habilitational services
Any
other types of services
[IF NEEDED: Other types of services
inside or outside the facility may include dieticians, nurse
practitioners, physician’s assistants, registered nurses, or
social workers.]
|
NO
YES
NOT
APPLICABLE
(-8) DON’T KNOW
(-9) REFUSED
|
NEXT QUESTION
|
TELCOVID
|
As of today, are any services provided through telehealth
by (FACILITY NAME) due to the coronavirus pandemic?
|
NO
YES
(-8) DON’T KNOW
(-9) REFUSED
|
(00) TELEMDS
(01) NEXT QUESTION
(-8) TELEMDS
(-9) TELEMDS
|
OUTDRTEL
|
[As of today] are doctor or other health professional visits
outside this facility currently offered through telehealth
due to the coronavirus pandemic? Please include outside
visits for both primary and specialty care.
VISITS SHOULD INCLUDE BOTH PRIMARY AND SPECIALTY CARE. IF
SERVICES ARE OFFERED THROUGH TELEHEALTH FOR EITHER PRIMARY OR
SPECIALITY CARE OUTSIDE THE FACILITY ANSWER “YES”.
|
(00) NO
(01) YES
(02) NOT APPLICABLE
(-8) DON’T KNOW
(-9) REFUSED
|
NEXT QUESTION
|
INDRTELE
|
[As of today] are doctor or other health professional visits
inside this facility currently offered through telehealth
due to the coronavirus pandemic? Please include inside
visits for both primary and specialty care.
VISITS SHOULD INCLUDE BOTH PRIMARY AND SPECIALTY CARE. IF
SERVICES ARE OFFERED THROUGH TELEHEALTH FOR EITHER PRIMARY OR
SPECIALITY CARE INSIDE THE FACILITY ANSWER “YES”.
|
(00) NO
(01) YES
(02) NOT APPLICABLE
(-8) DON’T KNOW
(-9) REFUSED
|
NEXT QUESTION
|
TELMED2
|
[As of today] which of the following services, both inside and
outside this facility, are currently offered through telehealth
due to the coronavirus pandemic?
Ask YES/NO for each:
Dental
visits
Psychiatrist
or other mental health professional visits
Podiatrist
visits
Educational
or habilitational services
Any
other types of services
[IF NEEDED: Other types of services
inside or outside the facility may include dieticians, nurse
practitioners, physician’s assistants, registered nurses, or
social workers.]
|
(00) NO
(01) YES
(02) NOT APPLICABLE
(-8) DON’T KNOW
(-9) REFUSED
|
NEXT QUESTION
|
TELEMDS
|
Due to the coronavirus pandemic, is (FACILITY NAME) currently
conducting any section of the Minimum Data Set Resident Assessment
and Care Screenings, also known as the MDS, via video calls, voice
calls, or conferencing over the internet, such as with Zoom,
Skype, or FaceTime?
|
NO
YES
NOT
APPLICABLE
(-8) DON’T KNOW
(-9) REFUSED
|
NEXT QUESTION
|
ACTINTRO
|
Now I would like to ask you about activities this facility may be
using to prevent the spread of COVID-19.
|
(01) CONTINUE
|
NEXT QUESTION
|
PREVVIS1
|
As of today, does (FACILITY NAME) currently allow
visitation, such as by family, friends, or volunteers?
[IF
NEEDED: Some examples may include allowing visitation for end of
life situations, making visitation decisions on a case by case
basis, or not restricting visitation at all.]
|
NO
YES
(-8) DON’T KNOW
(-9) REFUSED
|
(00) PREVVIS4
(01) NEXT QUESTION
(-8) PREVVIS4
(-9) PREVVIS4
|
PREVVIS3
|
If visitors are permitted inside, are they required to...
Ask YES/NO for each:
|
(00) NO
(01) YES
(-8) DON’T KNOW
(-9) REFUSED
|
NEXT QUESTION
|
PREVVIS4
|
Does this facility provide alternative methods for visitation such
as video conferencing for residents?
|
NO
YES
(-8) DON’T KNOW
(-9) REFUSED
|
NEXT QUESTION
|
PREVHCP1
|
Does this facility monitor health care personnel adherence to…
Ask YES/NO for each:
|
NO
YES
(-8) DON’T KNOW
(-9) REFUSED
|
NEXT QUESTION
|
HCPFLUVC
|
What is (FACILITY NAME)’s policy about the flu shot for
health care personnel? READ RESPONSE OPTIONS ALOUD:
Flu
shot is required
Flu
shot is recommended
Neither
|
(01) VACCINE IS REQUIRED
(02) VACCINE IS RECOMMENDED
(03) NEITHER
(-8) DON’T KNOW
(-9) REFUSED
|
NEXT QUESTION
|
HCPCOVVC
|
What will the (FACILITY NAME)’s policy be about the
Coronavirus vaccine for health care personnel? READ
RESPONSE OPTIONS ALOUD:
|
(01) VACCINE IS/WILL BE REQUIRED
(02) VACCINE IS/WILL BE RECOMMENDED
(03) NEITHER
(-8) DON’T KNOW
(-9) REFUSED
|
NEXT QUESTION
|
PREVRES1
|
Does this facility educate residents about…
Ask YES/NO for each:
COVID-19
symptoms and transmission
Actions
they can take to protect themselves such as hand washing
Actions the facility is taking
to keep them safe
|
(00) NO
(01) YES
(-8) DON’T KNOW
(-9) REFUSED
|
NEXT QUESTION
|
RESFLUVC
|
What is (FACILITY NAME)’s policy about the flu shot for
residents? READ RESPONSE OPTIONS ALOUD:
Flu
shot is required
Flu
shot is recommended
Neither
|
(01) VACCINE IS REQUIRED
(02) VACCINE IS RECOMMENDED
(03) NEITHER
(-8) DON’T KNOW
(-9) REFUSED
|
NEXT QUESTION
|
RESCOVVC
|
What will the (FACILITY NAME)’s policy be about the
Coronavirus vaccine for residents? READ RESPONSE OPTIONS
ALOUD:
|
(01) VACCINE IS/WILL BE REQUIRED
(02) VACCINE IS/WILL BE RECOMMENDED
(03) NEITHER
(-8) DON’T KNOW
(-9) REFUSED
|
NEXT QUESTION
|
FACLABCS
|
As of today, is there at least one laboratory-confirmed COVID-19
case in (FACILITY NAME)? Please include residents and facility
staff.
|
(00) NO
(01) YES
(-8) DON’T KNOW
(-9) REFUSED
|
NEXT QUESTION
|
ALTPROV1
|
As of today, have additional health care personnel been recruited
in (FACILITY NAME) beyond the usual health care personnel in this
facility in response to the coronavirus pandemic?
[IF NEEDED: Health care personnel
may have been recruited because facility staff have been sick with
or exposed to COVID-19.]
|
(00) NO
(01) YES
(-8) DON’T KNOW
(-9) REFUSED
|
(00) MENTHLTH
(01) ALTPROV2
(-8) MENTHLTH
(-9) MENTHLTH
|
ALTPROV2
|
What kind of health care personnel was that? SELECT ALL THAT
APPLY.
CODE
BASED ON THE RESPONSE FACILITY RESPONDENT GIVES:
|
(01) EMERGENCY MEDICAL SERVICE PERSONNEL
(02) NURSES
(03) NURSING ASSISTANTS
(04) NURSE PRACTITIONERS
(05) PHARMACISTS
(06) PHLEBOTOMISTS
(07) PHYSICIANS
(08) TECHNICIANS
(09) THERAPISTS
(10) NATIONAL GUARD
(11) OTHER
(-8) DON’T KNOW
(-9) REFUSED
|
NEXT QUESTION
|
MENTHLTH
|
The next questions are about mental health services.
|
(01) CONTINUE
|
NEXT QUESTION
|
MENTFAC
|
Does this facility offer…
Ask YES/NO to each:
|
(00) NO
(01) YES
(-8) DON’T KNOW
(-9) REFUSED
|
IF YES TO AT LEAST ONE SUPPORT SERVICE GO TO SUSPCOV
ELSE GO TO SOCINTRO
|
SUSPCOV
|
Are any of these support services currently suspended due to the
coronavirus pandemic?
|
(00) NO
(01) YES
(-8) DON’T KNOW
(-9) REFUSED
|
NEXT QUESTION
|
MTELESER
|
Are any of these support services currently shifted to an online
platform, such as Zoom, Skype, or FaceTime due to the coronavirus
pandemic?
|
(00) NO
(01) YES
(-8) DON’T KNOW
(-9) REFUSED
|
NEXT QUESTION
|
SOCINTRO
|
The next questions are about social and recreational activities.
|
(01) CONTINUE
|
|
ACTINFAC
|
Does this facility usually provide social and recreational
activities within the facility?
|
(00) NO
(01) YES
(-8) DON’T KNOW
(-9) REFUSED
|
NEXT QUESTION
|
ACTOUTFAC
|
Does this facility usually provide social and recreational
activities outside the facility?
“OUTSIDE THE FACILITY” REFERS TO ACTIVITES THAT
OCCUR OFF THE FACILITY PREMISES.
|
(00) NO
(01) YES
(-8) DON’T KNOW
(-9) REFUSED
|
BOX 1
|
BOX 1
|
IF ACTINFAC or ACTOUTFAC = (01) YES go to ACTSUSP
ELSE go to CVDINTRO
|
|
|
ACTSUSP
|
Are any of these activities currently suspended due to the
coronavirus pandemic?
|
(00) NO
(01) YES
(-8) DON’T KNOW
(-9) REFUSED
|
NEXT QUESTION
|
ACTTELE
|
Are any of these activities currently shifted to an online
platform, such as Zoom, Skype, or FaceTime due to the coronavirus
pandemic?
|
(00) NO
(01) YES
(-8) DON’T KNOW
(-9) REFUSED
|
NEXT QUESTION
|
Beneficiary-Level Questions
|
|
CVDINTRO
|
I am now going to ask you some questions about different types of
coronavirus tests (SP) may have had.
|
CONTINUE
|
NEXT QUESTION
|
CVDTEST
|
Since
(REFERENCE DATE) has (SP) been tested to
see whether (he/she) was infected with coronavirus or COVID-19 at
the time of the test?
[IF NEEDED: For example, the test
can be done by swabbing someone’s nose. This may also be
called a PCR test or a rapid test. It is not the same as an
antibody test, which looks at someone’s blood to see if they
have ever been infected.]
DO NOT INCLUDE ANTIBODY TESTS, WHICH
TEST WHETHER SOMEONE HAS EVER BEEN INFECTED WITH CORONAVIRUS.
|
(00) NO
(01) YES
(-8) Don't Know
(-9) Refused
|
(00) ANTICVD
(01) NEXT QUESTION
(-8) ANTICVD
(-9) ANTICVD
|
TESTRES
|
Did the test find that (SP) had Coronavirus or COVID-19?
|
(01) YES, THE TEST SHOWED R HAD COVID-19
(02) NO, THE TEST
SHOWED R DID NOT HAVE COVID-19
(03) NO RESULTS YET
(-8)
DON’T KNOW
(-9) REFUSED
|
NEXT QUESTION
|
ANTICVD
|
Since (REFERENCE DATE) has (SP) received an antibody test to
determine if (he/she) had Coronavirus or COVID-19 in the past?
[IF NEEDED: An antibody test looks at someone’s blood to
see if they have ever been infected with the coronavirus.]
|
(00) NO
(01) YES
(-8) Don't Know
(-9) Refused
|
(00) MEDICARE
(01) NEXT QUESTION
(-8) MEDICARE
(-9) MEDICARE
|
ANTIRES
|
Did the test find that (SP) had Coronavirus or COVID-19?
|
(01) YES, THE TEST SHOWED R HAD COVID-19
(02) NO, THE TEST
SHOWED R DID NOT HAVE COVID-19
(03) NO RESULTS YET
(-8)
DON’T KNOW
(-9) REFUSED
|
NEXT QUESTION
|
MEDICARE
|
Since (REFERENCE DATE) has (SP) received medical care (either
inside or outside this (facility/home)) for the coronavirus or
COVID-19?
[IF NEEDED: Please include services provided by all health care
personnel.]
|
(00) NO
(01) YES
(-8) Don't Know
(-9) Refused
|
(00) CDCVAC1
(01) NEXT QUESTION
(-8) CDCVAC1
(-9) CDCVAC1
|
PROVTYP
|
What kind of provider did (he/she) receive care from for the
coronavirus or COVID-19?SELECT ALL THAT APPLY.
CODE
BASED ON THE RESPONSE FACILITY RESPONDENT GIVES:
|
(01) EMERGENCY MEDICAL SERVICE PERSONNEL
(02) NURSES
(03) NURSING ASSISTANTS
(04) PHARMACISTS
(05) PHLEBOTOMISTS
(06) PHYSICIANS
(07) TECHNICIANS
(08) THERAPISTS
(09) OTHER
(-8) DON’T KNOW
(-9) REFUSED
|
NEXT QUESTION
|
CDCVAC1
|
Since (DATE of COVID-19 vaccine availability) has (SP) had a
COVID-19 vaccination?
|
(00) NO
(01) YES
(-8) DON’T KNOW
(-9) REFUSED
|
(01)
NEXT QUESTION
(00),
(-8), (-9) MDSINTRO
|
CVDVACNUM
|
How many COVID-19 vaccinations has (SP) had?
|
(01) One vaccination
(02) Two vaccinations
(-8) DON’T KNOW
(-9) REFUSED
|
(01),
(02) NEXT QUESTION
(-8), (-9) MDSINTRO
|
DOSEDAT1
|
Date of first dose of COVID-19 vaccination received –
Complete date and skip to the next section if response to question
two was 1; continue to next question if the response to
question two was 2. Month/Year
|
MONTH (VACMON1)
YEAR (VACYR1)
|
IF RESPONSE TO CVDVACNUM
=(02) GO TO DOSEDAT2.
ELSE GO TO MDSINTRO.
|
DOSEDAT2
|
Date of second COVID-19 vaccination received –
Complete date and skip to the next section Month/Year
|
MONTH (VACMON2)
YEAR (VACYR2)
|
NEXT QUESTION
|
MDSINTRO
|
MOOD
The next section is concerning (SP)’s mood on or around
(HS REF DATE).
|
(01) CONTINUE
|
NEXT QUESTION
|
PHQINTRO
|
MOOD
[3.0, D0100]
On or around (HS REF DATE) was a
Resident Mood Interview conducted for (SP)?
[IF NEEDED: This is sometimes referred to as the Patient Health
Questionnaire-9 or PHQ-9©. If an MDS has been
conducted for the resident, it can be found in section D0100.]
|
(00) NO
(01) YES
(-8) DON’T KNOW
(-9) REFUSED
|
(00) PHQSYMPT
(01) PHQSCORE
(-8) PHQSYMPT
(-9) PHQSYMPT
|
PHQSCORE
|
MOOD
[3.0, D0300]
ENTER SYMPTOM FREQUENCY SCORE
(00-27) FROM PHQ-9.
ENTER “99” IF THE
RESIDENT WAS UNABLE TO COMPLETE THE INTERVIEW.
|
(_ _) CONTINUOUS RESPONSE
(99) UNABLE TO COMPLETE INTERVIEW
|
THANKEND
|
PHQSYMPT
|
MOOD
[3.0, D0500]
Over the last 2 weeks, did the
resident have any of the following problems or behaviors?
IF THE FACILITY RESPONDENT IS UNSURE
AND THIS INFORMATION CANNOT BE FOUND IN THE MEDICAL CHART, BUT
THERE IS AN MDS AVAILABLE, YOU CAN REFERENCE THE MDS ITEM [3.0,
D0500].
Ask YES/NO for each:
A. Little interest or pleasure in
doing things.
B. Feeling or appearing down,
depressed, or hopeless.
C. Trouble falling or staying
asleep, or sleeping too much.
D. Feeling tired or having little
energy.
E. Poor appetite or overeating.
F. Indicating that s/he feels bad
about self, is a failure, or has let self or family down.
G. Trouble concentrating on things,
such as reading the newspaper or watching television.
H. Moving or speaking so slowly that
other people have noticed. Or the opposite - being so fidgety or
restless that s/he has been moving around a lot more than usual.
I. States that life isn't worth
living, wishes for death, or attempts to harm self.
J. Being short-tempered, easily
annoyed.
|
(00) NO
(01) YES
(-8) DON’T KNOW
(-9) REFUSED
|
If (01) YES TO ANY, GO TO PHQSYMFQ.
ELSE GO TO THANKEND
|
PHQSYMFQ
|
MOOD
[3.0, D0500]
Over the last 2 weeks, would you say
[INSERT PROBLEM OR BEHAVIOR FROM PHQSYMPT] was exhibited never or
1 day, for 2 to 6 days (several days), for 7 to 11 days (half or
more of the days), or for 12-14 days (nearly every day)?
COLLECT SYMPTOM FREQUENCY FOR EACH PROBLEM/BEHAVIOR THAT IS
REPORTED “YES”
|
(00) Never or 1 day
(01) 2-6 days (several days)
(02) 7-11 days (half or more of the
days)
(03) 12-14 days (nearly every day)
|
NEXT QUESTION
|
THANKEND
|
Thank you for participating in this important survey.
|
|
|