Form 0920-0214 Sample Adult

Attachment A:

COVID-Related Questions for NHIS Starting in July 2020

POSITIVE COVID-19 CASES

Sample Adults 18+ and Sample Children 0-17

1) Has a doctor or other health professional ever told you that [you / ^SCNAME] had or likely had coronavirus or COVID-19?

1 – Yes

2 – No

Refused/Don’t Know

2) [Have you / Has ^SCNAME] ever been tested for coronavirus or COVID-19?

1 – Yes

2 – No

Refused/Don’t Know

<1> [goto Question #3]

<2,RF,DK> [goto Question #4]

3) Did the test find that [you / ^SCNAME] had coronavirus or COVID-19?

FR Instruction: If any test has shown they have COVID-19, enter 1 for yes. If the person indicates they are waiting for their results, enter 3 for Did not receive results. If the respondent indicates the test was inconclusive, enter 'CTRL-D' for Don't Know.

1 – Yes

2 – No

3 – Did not receive results

Refused/Don’t Know

4) How would you describe [your / ^SCNAME’s] coronavirus symptoms when they were at their worst? Would you say no symptoms, mild symptoms, moderate symptoms, or severe symptoms?

1 – No symptoms

2 – Mild symptoms

3 – Moderate symptoms

4 – Severe symptoms

Refused/Don’t Know

UNDERLYING HEALTH CONDITIONS

Sample Adults 18+

Have you EVER been told by a doctor or other health professional that you had …

1) … Weak or failing kidneys?

Read if necessary: Do not include kidney stones, bladder infections, or incontinence.

2) … Hepatitis?

3) … Cirrhosis or any other kind of long-term liver condition?

IMMUNOSUPPRESSION

Sample Adults 18+

1) In the past 12 months, have you taken prescription medication or had any medical treatments that a doctor or other health professional told you would weaken your immune system?

Read if necessary: Examples include steroid or corticosteroid pills, such as prednisone, or other oral or injected medications for treating many types of autoimmune conditions or certain cancers.

1 – Yes

2 – No

Refused/Don’t Know

2) Do you currently have a health condition that a doctor or other health professional told you weakens the immune system [If #1 = Yes, fill:, even without related medications or treatments]?

Read if necessary: Examples include certain kinds of leukemia, lymphoma, or HIV infection.

1 – Yes

2 – No

Refused/Don’t Know

ACCESS TO CARE

Sample Adults 18+ and Sample Children 0-17

1) Was there any time when [you / ^SCNAME] DELAYED getting medical care because of the coronavirus pandemic?

1 – Yes

2 – No

Refused/Don’t Know

2) Was there any time when [you / ^SCNAME] needed medical care for something other than coronavirus, but DID NOT GET IT because of the coronavirus pandemic?

1 – Yes

2 – No

Refused/Don’t Know

3) In past 12 months, [have you / has ^SCNAME] had an appointment with a doctor, nurse, or other health professional by video or by phone?

1 – Yes

2 – No

Refused/Don’t Know

<1> [goto Question #4]

<2,RF,DK> [goto next section]

4) Were any of [your / ^SCNAME’s] appointments done by video or by phone because of reasons related to the coronavirus pandemic?

1 – Yes

2 – No

Refused/Don’t Know

ACCESS TO CANCER CARE

Sponsored by NCI and NCCDPHP

Sample Adults 18+ ever diagnosed with cancer

1) The next question refers to treatments for cancer such as surgery, radiation therapy, chemotherapy, bone marrow transplants, stem cell transplants, or hormone therapy. At any time since the start of the coronavirus pandemic, were you in treatment or supposed to receive treatment for your cancer?

Read if necessary: Hormone therapy includes Tamoxifen, Fulvestrant (full-VESS-trant) or Aromatase (uh-ROH-muh-tayz) inhibitors for breast cancer and androgen therapy such as Eligard or Zoladex for prostate cancer.

1 – Yes

2 – No

Refused/Don’t Know

<1> [goto Question #2]

<2,RF,DK> [goto Question #3]

2) Were any of your treatments for cancer changed, delayed, or cancelled because of the coronavirus pandemic?

1 – Yes

2 – No

Refused/Don’t Know

3) As a cancer patient or cancer survivor, you may need OTHER medical care related to your cancer such as lab visits, imaging, monitoring visits, rehabilitation, physical therapy, care for side-effects, or visits with medical specialists. At any time since the start of the coronavirus pandemic, did you need any of this OTHER medical care related to your cancer?

1 – Yes

2 – No

Refused/Don’t Know

<1> [goto Question #4]

<2,RF,DK> [goto next section]

4) Was any of this other medical care related to your cancer changed, delayed, or cancelled because of the coronavirus pandemic?

1 – Yes

2 – No

Refused/Don’t Know

ACCESS TO SKILLED AND INFORMAL CAREGIVING

Sample Adults 18+

1) During the past 12 months, did you receive care at home from a nurse or other health professional?

Question #1 is already included in the 2020 NHIS rotating content. It is included here to provide context for the questions that follow.

1 – Yes

2 – No

Refused/Don’t Know

2) (If after March 2021: During the past 12 months, . . .) Was there any time when you needed care at home from a nurse or other health professional but DID NOT GET IT because of the coronavirus pandemic?

1 – Yes

2 – No

Refused/Don’t Know

3) During the past 12 months, did you receive care at home from a friend or family member?

If the respondent asks what is meant by the term "care," say: "A wide range of activities that a person may need help with can be considered care. For example, care at home can include personal tasks such as giving medications or helping with eating, dressing, or bathing or household tasks such as cleaning, managing money, or preparing meals."

1 – Yes

2 – No

Refused/Don’t Know

4) (If after March 2021: During the past 12 months, . . .) Was there any time when you needed care at home from a friend or family member but DID NOT GET IT because of the coronavirus pandemic?

1 – Yes

2 – No

Refused/Don’t Know

<1,2,RF,DK> [If #2 and #3 = yes, goto Question #5; else goto next section]

5) Did a friend or family member provide some or all of the care that a nurse or other health professional did not provide due to the coronavirus pandemic?

1 – Yes

2 – No

Refused/Don’t Know

SOCIAL SUPPORT

Sample Adults 18+

1) How often do you get the social and emotional support you need?

1 – Always

2 – Usually

3 – Sometimes

4 – Rarely

5 – Never

Refused/Don’t Know

2) Compared with 12 months ago, would you say that you now receive more social and emotional support, less social and emotional support, or about the same?

1 – More social and emotional support

2 – Less social and emotional support

3 – About the same

Refused/Don’t Know

IMPACT OF CHRONIC PAIN

Sample Adults 18+ who had pain some days, most days, or every day in the past 3 months

1) Over the past three months, how often did your pain limit your life or work activities? Would you say never, some days, most days, or every day?

1 – Never

2 – Some days

3 – Most days

4 – Every day

Refused/Don’t Know

2) Over the past three months, how often did YOUR pain affect your family and significant others? Would you say never, some days, most days, or every day?

1 – Never

2 – Some days

3 – Most days

4 – Every day

Refused/Don’t Know

SOCIAL DISTANCING AT CURRENT JOB

Sponsored by NIOSH

Sample Adults 18+ who are currently employed

1) Thinking about your MAIN job or business, are there currently social distancing measures in effect to help keep people apart?

1 – Yes

2 – No

Refused/Don’t Know

<1> [goto Question #2]

<2,RF,DK> [goto Question #4]

Questions #2 and #3 are for employed adults whose job has social distancing in effect

2) Currently, at your MAIN job or business, how often do you still need to work closer than 6 feet to other people? [Contact with social distancing measures]

1 – All of the time

2 – Most of the time

3 – Some of the time

4 – None of the time

Refused/Don’t Know

3) When social distancing measures were NOT in effect, how often did you need to work closer than 6 feet to other people? [Contact without social distancing measures]

1 – All of the time

2 – Most of the time

3 – Some of the time

4 – None of the time

5 – Only worked at current main job while social distancing measures were in effect

Refused/Don’t Know

<1,2,3,4,RF,DK> [goto next section]

Questions #4-6 are for employed adults whose job does not have social distancing in effect

4) Currently, at your MAIN job or business, how often do you need to work closer than 6 feet to other people? [Contact without social distancing measures]

1 – All of the time

2 – Most of the time

3 – Some of the time

4 – None of the time

Refused/Don’t Know

5) At any time since the start of the coronavirus pandemic, did your MAIN job or business put social distancing measures into effect?

1 – Yes

2 – No

Refused/Don’t Know

<1> [goto Question #6]

<2,RF,DK> [goto next section]

6) When social distancing measures were in effect, how often did you need to work closer than 6 feet to other people? [Contact with social distancing measures]

1 – All of the time

2 – Most of the time

3 – Some of the time

4 – None of the time

5 – Did not work at main job when social distancing measures were in effect

Refused/Don’t Know

SOCIAL DISTANCING AT RECENT JOB

Sponsored by NIOSH

Sample Adults 18+ who are unemployed now but employed in past 12 months

1) Thinking about the MAIN job you held in the past 12 months, were there ever any social distancing measures in effect while you worked there? That is, were there ever practices in place to help keep people apart?

1 – Yes

2 – No

Refused/Don’t Know

<1> [goto Question #2]

<2,RF,DK> [goto Question #4]

2) When social distancing measures were in effect, how often did you still need to work closer than 6 feet to other people? [Contact with social distancing measures]

1 – All of the time

2 – Most of the time

3 – Some of the time

4 – None of the time

Refused/Don’t Know

3) When social distancing measures were not in effect, how often did you need to work closer than 6 feet to other people? [Contact without social distancing measures]

1 – All of the time

2 – Most of the time

3 – Some of the time

4 – None of the time

5 – Only worked at main job while social distancing measures were in effect

Refused/Don’t Know

<1,2,3,4,RF,DK> [goto next section]

4) How often did you need to work closer than 6 feet to other people? [Contact without social distancing measures]

1 – All of the time

2 – Most of the time

3 – Some of the time

4 – None of the time

Refused/Don’t Know

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