P-0015A COVID-19 Questionnaire Specifications

2021 MCBS Community Questionnaire

CVQ-COVID-19

COVID-19 Questionnaire Specifications
Var Name
LANGUAGE

Question Text/Description
PLEASE SELECT THE LANGUAGE IN WHICH YOU
WOULD LIKE TO CONDUCT THE INTERVIEW.

Response Options
(01) ENGLISH
(02) SPANISH

Routing
NEXT QUESTION

INTROQ

Thank you for agreeing to participate in this short
survey about [your/RESPONDENT’S NAME]
experiences during the coronavirus pandemic,
also known as COVID-19 or SARS-CoV-2.
All survey information will be kept private to the
extent permitted by law, as prescribed by the
Privacy Act of 1974.

(01) CONTINUE

NEXT QUESTION

(01) CONTINUE

NEXT QUESTION

(01) YES
(02) NO

(01) SPSTATUS
(02) SPCORNAM

(01) CONTINUE

SPSTATUS

ATDOOR

SPVERNAM

SPCORNAM

Medicare benefits will not be affected in any way
by survey responses or participation.
VERIFY THE SP’S NAME. IS THE SP’S NAME
CORRECT AND COMPLETE?
FIRST NAME: [FIRST_NAME]
MIDDLE INITIAL: [MIDDLE_NAME]
LAST NAME: [LAST_NAME]
MAKE ALL NECESSARY CORRECTIONS TO THE SP'S
NAME.
SPFNAME. FIRST NAME:
SPMIDIN. MIDDLE INITIAL:
SPLNAME. LAST NAME:

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Var Name
SPSTATUS

INTHANK

SPPROXIN
SPRELATE

Question Text/Description
PLEASE INDICATE THE RESPONDENT’S CURRENT
STATUS. IF THE CASE IS A PROXY INTERVIEW AND
YOU HAVEN’T TALKED ABOUT THE RESPONDENT’S
VITAL STATUS, PROBE AT THIS TIME ABOUT
WHETHER THE RESPONDENT IS ALIVE OR
DECEASED AND WHERE THE RESPONDENT IS
LOCATED.

Response Options
(01) ALIVE AND NOT INSTITUTIONALIZED
(02) ALIVE AND INSTITUTIONALIZED
(03) DECEASED – DIED IN COMMUNITY
(04) DECEASED – DIED IN
INSTITUTION/FACILITY

Routing
(01) SPPROXIN
(02) INTHANK
(03) INTHANK
(04) INTHANK

(01) SAMPLE PERSON
(02) PROXY
(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

(01) HLTHINT
(02) SPRELATE
NEXT QUESTION

CVQ-COVID-19

IS THE RESPONDENT CURRENTLY:
THIS CASE IS NOT ELIGIBLE FOR THE
[MCBS/NGACO] CORONAVIRUS SURVEY.
THANK THE RESPONDENT THEN PRESS NEXT.
ONCE YOU SYNC NORC SUITE THE CASE WILL BE
CODED WITH THE APPROPRIATE INELIGIBLE
DISPOSITION.
WILL THIS INTERVIEW BE CONDUCTED WITH THE
SAMPLE PERSON OR WITH A PROXY?
[What is the relationship to (SP)?]

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Var Name

Question Text/Description

PROXYWHY

WHAT IS THE MAIN REASON THAT A PROXY
RESPONDENT IS NECESSARY?

HLTHINT

The first set of questions are about [your/SP’s]
experiences using health care services.
Is there a particular doctor or other health
professional, or a clinic [you/(SP)] usually
[go/goes] to when [you are/he is/she is] are sick
or for advice about [your/SP’s] health?

PLACPART

Response Options
Routing
(52) BOARDER
(53) NURSE/NURSE'S AIDE
(54) LEGAL/FINANCIAL OFFICER
(55) GUARDIAN
(56) PARTNER
(57) ROOMMATE
(91) OTHER
(-8) DON'T KNOW
(-7) REFUSED
(01) SP NOT CAPABLE
HLTHINT
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
(91) OTHER
(01) CONTINUE
NEXT QUESTION
(01) YES
(02) NO
(-8) DON'T KNOW
(-7) REFUSED

CVQ-COVID-19

(01) PLACKIND
(02) COMPUTER
(-8) COMPUTER
(-7) COMPUTER

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Var Name
PLACKIND

Question Text/Description
What kind of place [do you/does (SP)] usually go
to when [you are/he is/she is] sick or for advice
about [your/his/her] 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?
CODE BASED ON THE RESPONSE R GIVES:

Response Options
(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
(-7) REFUSED

Routing
NEXT QUESTION

CVQ-COVID-19

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Var Name
TELMED

Question Text/Description
Does [your/(SP)’s] usual provider offer telephone
or video appointments, so that [you don’t/he/she
doesn’t] need to physically visit their office or
facility?

Response Options
(01) YES
(02) NO
(-8) DON'T KNOW
(-7) REFUSED

CVQ-COVID-19

Routing
(01) NEXT QUESTION
(02) COMPUTER
(-8) COMPUTER
(-7) COMPUTER

[IF NEEDED: Did [your/(SP)’s] provider offer to talk
to [you/him/her] about [your/his/her] symptoms
over the phone or video so that [you/he/she]
wouldn’t have to visit their office or facility?]

TELMEDT1

TELMEDBE

TELMEDT2

[IF NEEDED: Telephone appointments may include
“audio-only” appointments.]
Do they offer telephone appointments, video
(01) TELEPHONE
appointments, or both?
(02) VIDEO
(03) BOTH
FOR “AUDIO-ONLY” APPOINTMENTS, SELECT
(-8) DON’T KNOW
“TELEPHONE”.
(-7) REFUSED
Did [your/(SP)’s] usual provider offer telephone or (01) YES
video appointments before the coronavirus
(02) NO
pandemic?
(-8) DON'T KNOW
(-7) REFUSED
[IF NEEDED: Telephone appointments may include
“audio-only” appointments.]
Did they offer telephone appointments, video
(01) TELEPHONE
appointments, or both?
(02) VIDEO
(03) BOTH
FOR “AUDIO-ONLY” APPOINTMENTS, SELECT
(-8) DON’T KNOW
“TELEPHONE”.
(-7) REFUSED

NEXT QUESTION

(01) NEXT QUESTION
(02) TELMEDDU
(-8) TELMEDDU
(-7) TELMEDDU
NEXT QUESTION

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Var Name
TELMEDDU

TELMEDT3

TELMEDUS

TELMEDT4

Question Text/Description
Since (REFERENCE DATE), did [your/(SP)’s] usual
provider offer [you/him/her] a telephone or video
appointment to replace a regularly scheduled
appointment?

Response Options
(01) YES
(02) NO
(-8) DON'T KNOW
(-7) REFUSED

[IF NEEDED: Telephone appointments may include
“audio-only” appointments.]
Did they offer telephone appointments, video
(01) TELEPHONE
appointments, or both?
(02) VIDEO
(03) BOTH
(-8) DON’T KNOW
FOR “AUDIO-ONLY” APPOINTMENTS, SELECT
“TELEPHONE”.
(-7) REFUSED
Since (REFERENCE DATE), [have you/has (SP)] had (01) YES
an appointment with a doctor or other health
(02) NO
professional by telephone or video?
(-8) DON'T KNOW
(-7) REFUSED
[IF NEEDED: Telephone appointments may include
“audio-only” appointments.]
Was it a telephone appointment, video
(01) TELEPHONE
appointment, or both?
(02) VIDEO
(03) BOTH
FOR “AUDIO-ONLY” APPOINTMENTS, SELECT
(-8) DON’T KNOW
“TELEPHONE”.
(-7) REFUSED

CVQ-COVID-19

Routing
(01) NEXT QUESTION
(02) TELMEDUS
(-8) TELMEDUS
(-7) TELMEDUS

NEXT QUESTION

(01) NEXT QUESTION
(02) COMPUTER
(-8) COMPUTER
(-7) COMPUTER
NEXT QUESTION

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Var Name
COMPUTER

Question Text/Description
The next questions ask about use of the internet.
[Do you/Does (SP)] own or use any of the
following types of computers? Please tell me yes
or no for each item I list.

Response Options
(01) YES
(02) NO
(-8) DON'T KNOW
(-7) REFUSED

Routing
NEXT QUESTION

(01) YES
(02) NO
(-8) DON'T KNOW
(-7) REFUSED
(01) YES
(02) NO
(-8) DON'T KNOW
(-7) REFUSED

NEXT QUESTION

CVQ-COVID-19

COMPDESK. Desktop or laptop
COMPPHON. Smartphone
COMPTAB. Tablet or other portable wireless
computer
INTERNET

[Do you/ Does (SP)] have access to the internet?

AUDIOVID

Since (REFERENCE DATE), [have you (ever)/has
(SP) (ever)] participated in video or voice calls or
conferencing over the internet, such as with
Zoom, Skype, or FaceTime?

NEXT QUESTION

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Var Name
COVIDCAR

Question Text/Description
Now I’d like to ask about care [you were/(SP) was]
unable to get because of the coronavirus
pandemic.

Since (REFERENCE DATE), did [you/(SP)] need
medical care for something other than
coronavirus, but not get it because of the
coronavirus pandemic?

NOCARTY1

[IF NEEDED: [Have you/Has (SP)] had any medical
appointments rescheduled since (REFERENCE
DATE) because of the coronavirus pandemic? Or,
[have you/has he/has she] needed a medical
appointment but [were/was] unable to schedule
one because of the coronavirus pandemic?]
Since (REFERENCE DATE), [were you/was (SP)]
unable to get any of the following types of care
because of the coronavirus pandemic?
[IF NEEDED: Please include preventative tests like
mammograms and colonoscopies as “Diagnostic
or Medical Screening Test”]

Response Options
(01) YES
(02) NO
(-8) DON'T KNOW
(-7) REFUSED

Routing
(01) NOCARTY1
(02) AUTOINT
(-8) AUTOINT
(-7) AUTOINT

(01) YES
(02) NO
(03) NOT APPLICABLE
(-8) DON’T KNOW
(-7) REFUSED

NEXT QUESTION

CVQ-COVID-19

READ EACH ITEM AND RECORD YES/NO
RESPONSE:
TYPURGNT. Urgent Care for an Accident or Illness
TYPSURGE. A Surgical Procedure
TYPDIAGN. Diagnostic or Medical Screening Test
TYPTREAT. Treatment for an Ongoing Condition
TYPCHKUP. A Regular Check-up

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2021 MCBS Community Questionnaire

Var Name
NOCARTY2

Question Text/Description
[Since (REFERENCE DATE), [were you/was (SP)]
unable to get any of the following types of care
because of the coronavirus pandemic?]
READ EACH ITEM AND RECORD YES/NO
RESPONSE:
TYPDRUGS. Prescription drugs or medications
TYPDENTA. Dental Care
TYPVISIO. Vision Care
TYPHEAR. Hearing Care
TYPMENT. Mental Health Care

NOCARDIR
DIRURGNT
DIRSURGE
DIRDIAGN
DIRTREAT
DIRCHKUP
DIRDRUGS
DIRDENTA
DIRVISIO
DIRHEAR
DIRMENT

Regarding [your/(SP)’s] [NOCARTY1/NOCARTY2],
did [your/his/her] medical provider make this
decision or did [you/he/she]?
[IF NEEDED: If [you/(SP)] had contact with
[your/his/her] medical provider about rescheduling or canceling an appointment for care,
but they gave [you/him/her] the option to keep
[your/his/her] originally-scheduled appointment,
please answer that [you/he/she] decided not to
get care.]

Response Options
(01) YES
(02) NO
(03) NOT APPLICABLE
(-8) DON’T KNOW
(-7) REFUSED

CVQ-COVID-19

Routing
FOR EACH TYPE OF
CARE SELECTED AT
NOCARTY1 AND
NOCARTY2, ASK
NOCARDIR
AND THE APPLICABLE
FOLLOW-UP:
IF YES SELECTED FOR
ANY ITEMS, GO TO
NOCARDIR.

(01) PROVIDER DECIDED
(02) R DECIDED
(03) BOTH
(-8) DON’T KNOW
(-7) REFUSED

IF NO TYPES SELECTED
AT NOCARTY1 AND
NOCARTY2, SKIP TO
AUTOINT.
(01) REASONMD
(02) NOCARYR
(03) REASONMD
(-8) AUTOINT
(-7) AUTOINT

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2021 MCBS Community Questionnaire

Var Name
REASONMD
RSNURGNT
RSNSURGE
RSNDIAGN
RSNTREAT
RSNCHKUP
RSNDRUGS
RSNDENTA
RSNVISIO
RSNHEAR
RSNMENT

Question Text/Description
Did [your/(SP)’s] medical provider give
[you/him/her] a reason why they needed to
reschedule?

Response Options
(01) YES
(02) NO
(-8) DON’T KNOW
(-7) REFUSED

Routing
(01) NOCARYMD

CVQ-COVID-19

(02), (-8), (-7):
IF NOCARDIR= “BOTH”
GO TO NOCARYR.
ELSE, IF MORE THAN
ONE TYPE OF CARE
SELECTED AT
NOCARTY1 OR
NOCARTY2, GO BACK
TO NOCARDIR AND
ASK ABOUT THE NEXT
CONDITION.
ELSE, GO TO
AUTOINT.

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2021 MCBS Community Questionnaire

NOCARYMD

What reasons [were you/was (SP)] given by
[your/his/her] provider for this decision regarding
[ITEM SELECTED AT NOCARTY1 OR NOCARTY2]?
READ EACH ITEM AND RECORD YES/NO
RESPONSE:
(01) Was the medical office closed?
CLSURGNT
CLSSURGE
CLSDIAGN
CLSTREAT
CLSCHKUP
CLSDRUGS
CLSDENTA
CLSVISIO
CLSHEAR
CLSMENT

(01) YES
(02) NO
(-8) DON’T KNOW
(-7) REFUSED

CVQ-COVID-19

IF NOCARDIR= “BOTH”
GO TO NOCARYR.
ELSE, IF MORE THAN
ONE TYPE OF CARE
SELECTED AT
NOCARTY1 OR
NOCARTY2, GO BACK
TO NOCARDIR AND
ASK ABOUT THE NEXT
CONDITION.
ELSE, GO TO
AUTOINT.

(02) Was priority given to other types of
appointments?
PRIURGNT
PRISURGE
PRIDIAGN
PRITREAT
PRICHKUP
PRIDRUGS
PRIDENTA
PRIVISIO
PRIHEAR
PRIMENT
(03) Did the medical office reduce available
appointments?

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Var Name

Question Text/Description
REDURGNT
REDSURGE
REDDIAGN
REDTREAT
REDCHKUP
REDDRUGS
REDDENTA
REDVISIO
REDHEAR
REDMENT

Response Options

Routing

CVQ-COVID-19

(04) Was there some other reason?
OMDURGNT
OMDSURGE
OMDDIAGN
OMDTREAT
OMDCHKUP
OMDDRUGS
OMDDENTA
OMDVISIO
OMDHEAR
OMDMENT

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2021 MCBS Community Questionnaire

NOCARYR

What reasons did [you/(SP)] have for
[your/his/her] decision regarding [ITEM SELECTED
AT NOCARTY1 OR NOCARTY2]?
READ EACH ITEM AND RECORD YES/NO
RESPONSE:

(01) Did [you/he/she] have no access to
transportation?
TRAURGNT
TRASURGE
TRADIAGN
TRATREAT
TRACHKUP
TRADRUGS
TRADENTA
TRAVISIO
TRAHEAR
TRAMENT

(01) YES
(02) NO
(-8) DON’T KNOW
(-7) REFUSED

CVQ-COVID-19

IF MORE THAN ONE
TYPE OF CARE WAS
SELECTED AT
NOCARTY1 OR
NOCARTY2, GO TO
NOCARDIR AND ASK
ABOUT NEXT TYPE.
OTHERWISE, GO TO
AUTOINT.

(02) Did [you/he/she] not want to leave
[your/his/her] house?
HOUURGNT
HOUSURGE
HOUDIAGN
HOUTREAT
HOUCHKUP
HOUDRUGS
HOUDENTA
HOUVISIO
HOUHEAR
HOUMENT
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Var Name

Question Text/Description
Response Options
(03) Did [you/he/she] not want to risk being at
a medical facility?
RSKURGNT
RSKSURGE
RSKDIAGN
RSKTREAT
RSKCHKUP
RSKDRUGS
RSKDENTA
RSKVISIO
RSKHEAR
RSKMENT

Routing

CVQ-COVID-19

(04) Was there some other reason?
OYRURGNT
OYRSURGE
OYRDIAGN
OYRTREAT
OYRCHKUP
OYRDRUGS
OYRDENTA
OYRVISIO
OYRHEAR
OYRMENT
AUTOINT

The next questions are about health conditions
[you/(SP)] may have.

(01) CONTINUE

NEXT QUESTION

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CVQ-COVID-19

Var Name
AUTOIMRX

Question Text/Description
Since (REFERENCE DATE), [have you/has (SP)]
taken prescription medication or had any medical
treatments that a doctor or other health
professional told [you/him/her] would weaken
[your/his/her] immune system?

Response Options
(01) YES
(02) NO
(-8) DON’T KNOW
(-7) REFUSED

Routing
NEXT QUESTION

AUTOCND

[Do you/Does (SP)] currently have a health
condition that a doctor or other health
professional told [you/him/her] weakens the
immune system?
Now I want to ask you some questions about the
recent coronavirus pandemic, also known as
COVID-19 or SARS-CoV-2.
IF P_PRIORCOVID=YES THEN GO TO ANTBDTST.
ELSE GO TO SUSPECT.
Since (REFERENCE DATE), [have you/has (SP)]
suspected that [you have/he has/she has] (ever)
had the coronavirus or COVID-19?

(01) YES
(02) NO
(-8) DON’T KNOW
(-7) REFUSED
CONTINUE

NEXT QUESTION

(01) YES
(02) NO
(-8) DON'T KNOW
(-7) REFUSED

(01) NEXT QUESTION
(02) COVIDEV
(-8) COVIDEV
(-7) COVIDEV

COVIDINT
BOX B
SUSPECT

BOX B

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Var Name
SUSPECTY

Question Text/Description
What symptoms did [you/(SP)] have that made
[you/him/her/they] suspect [you/he/she] (ever)
had the coronavirus?
INTERVIEWER CODE BASED ON VERBATIM
RESPONSE FROM RESPONDENT.

COVIDEV

Since (REFERENCE DATE), has a doctor or other
health professional (ever) told [you/(SP)] that
[you have/he has/she has] or likely had
coronavirus or COVID-19?

Response Options
(01) SUSFEVER FEVER
(02) SUSCOUGH ONGOING DRY COUGH
(03) SUSRNOSE RUNNY NOSE
(04) SUSSNEEZ SNEEZING
(05) SUSSRTBR SHORTNESS OF BREATH
(06) SUSHDACH HEADACHE
(07) SUSTHROA SORE THROAT
(08) SUSNAUSE NAUSEA
(09) SUSVOMIT VOMITING
(10) SUSFATIG EXTREME FATIGUE
(11) SUSCHILL CHILLS/REPEATED
SHAKING WITH CHILLS
(12) SUSMUSCL MUSCLE PAIN
(13) SUSLTSSM NEW LOSS OF TASTE OR
SMELL
(14) SUSLAPPE LOSS OF APPETITE
(15) SUSDIAH DIARRHEA
(91) SUSOTHER OTHER
(-8) DON'T KNOW
(-7) REFUSED
(01) YES
(02) NO
(-8) DON'T KNOW
(-7) REFUSED

Routing
NEXT QUESTION

CVQ-COVID-19

NEXT QUESTION

[IF NEEDED: A doctor or other health professional
might make this diagnosis based on a test for
COVID-19 or based on symptoms [you have/(SP)]
has].

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Var Name
COVSWAB

Question Text/Description
Since (REFERENCE DATE), [have you (ever)
/has(SP) (ever)] been tested to see whether [you
were/he was/she was] infected with coronavirus
or COVID-19 at the time of the test?

Response Options
(01) YES
(02) NO
(-8) DON'T KNOW
(-7) REFUSED

Routing
(01) SWABRSLT
(02) ANTBDTST
(-8) ANTBDTST
(-7) ANTBDTST

(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
(-7) REFUSED

(01) SWABWAIT
(02) SWABWAIT
(03) CVTSTPAY
(-8) CVTSTPAY
(-9) CVTSTPAY

CVQ-COVID-19

[IF NEEDED: For example, the test can be done by
swabbing [your/his/her] nose or mouth.]
[IF NEEDED: If [you/(SP)] have had more than one
test to see whether [you were/he was/she was]
infected with coronavirus or COVID-19 at the time
of the test, think about your most recent test.]
DO NOT INCLUDE ANTIBODY TESTS, WHICH TEST
WHETHER SOMEONE HAS EVER BEEN INFECTED
WITH CORONAVIRUS.
SWABRSLT

Did the test find that [you/(SP)] had Coronavirus
or COVID-19?
[IF NEEDED: If [you/(SP)] have had more than one
test to see whether [you were/he was/she was]
infected with coronavirus or COVID-19 at the time
of the test, think about your most recent test.]
DO NOT INCLUDE ANTIBODY TESTS, WHICH TEST
WHETHER SOMEONE HAS EVER BEEN INFECTED
WITH CORONAVIRUS.

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Var Name
SWABWAIT

Question Text/Description
How long did it take to get [your/(SP)’s] test
results? Did [you/he/she] get the results the same
day, the next day, within 2-3 days, within 4-6
days, or after 8 days or more?
[IF NEEDED: If [you/(SP)] have had more than one
test to see whether [you were/he was/she was]
infected with coronavirus or COVID-19 at the time
of the test, think about your most recent test.]

Response Options
(01) SAME DAY
(02) NEXT DAY
(03) 2-3 DAYS
(04) 4-6 DAYS
(05) 7 DAYS OR MORE
(-8) DON’T KNOW
(-7) REFUSED

Routing
NEXT QUESTION

(01) NONE OF THE COST
(02) PART OF THE COST
(03) ALL OF THE COST
(-8) DON'T KNOW
(-7) REFUSED

NEXT QUESTION

CVQ-COVID-19

DO NOT INCLUDE ANTIBODY TESTS, WHICH TEST
WHETHER SOMEONE HAS EVER BEEN INFECTED
WITH CORONAVIRUS.
CVTSTPAY

How much did [you/(SP)] pay out of pocket for
the test: none of the cost, part of the cost, or all
of the cost?
[IF NEEDED: Please answer to the best of your
knowledge.]
[IF NEEDED: If [you/(SP)] have had more than one
test to see whether [you were/he was/she was]
infected with coronavirus or COVID-19 at the time
of the test, think about your most recent test.]
DO NOT INCLUDE ANTIBODY TESTS, WHICH TEST
WHETHER SOMEONE HAS EVER BEEN INFECTED
WITH CORONAVIRUS.

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Var Name
ANTBDTST

Question Text/Description
Since (REFERENCE DATE), have [you (ever)/(SP)
(ever)] received an antibody test to determine if
[you/he/she] ever had the coronavirus?
[IF NEEDED: An antibody test looks at someone’s
blood to see if they have ever been infected with
the coronavirus.]

Response Options
(01) YES
(02) NO
(-8) DON'T KNOW
(-7) REFUSED

Routing
(01) ANTRESLT
(02) BOX A
(-8) BOX A
(-7) BOX A

(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
(-7) REFUSED

(01) ANTWAIT
(02) ANTWAIT
(03) ANTPAY
(-8) ANTPAY
(-9) ANTPAY

(01) SAME DAY
(02) NEXT DAY
(03) 2-3 DAYS
(04) 4-6 DAYS
(05) 7 DAYS OR MORE
(-8) DON’T KNOW

NEXT QUESTION

CVQ-COVID-19

[IF NEEDED: If [you/(SP)] have had more than one
antibody test to determine if [you/he/she] ever
had the coronavirus, think about your most
recent test.]
ANTRESLT

Did the test find that [you/(SP)] had Coronavirus
or COVID-19?
[IF NEEDED: An antibody test looks at someone’s
blood to see if they have ever been infected with
the coronavirus.]
[IF NEEDED: If [you/(SP)] have had more than one
antibody test to determine if [you/he/she] ever
had the coronavirus, think about your most
recent test.]

ANTWAIT

How long did it take to get [your/(SP)’s] antibody
test results? Did [you/he/she] get the results the
same day, the next day, within 2-3 days, within 46 days, or after 7 days or more?

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2021 MCBS Community Questionnaire

Var Name

Question Text/Description
[IF NEEDED: If [you/(SP)] have had more than one
antibody test to determine if [you/he/she] ever
had the coronavirus, think about your most
recent test.]

Response Options
(-7) REFUSED

Routing

ANTPAY

How much did [you/(SP)] pay out of pocket for
the test: none of the cost, part of the cost, or all
of the cost?

(01) NONE OF THE COST
(02) PART OF THE COST
(03) ALL OF THE COST
(-8) DON'T KNOW
(-7) REFUSED

BOX A

(01) NO SYMPTOMS
(02) MILD SYMPTOMS
(03) MODERATE SYMPTOMS
(04) SEVERE SYMPTOMS
(-8) DON'T KNOW

NEXT QUESTION

[IF NEEDED: Please answer to the best of your
knowledge.]

CVQ-COVID-19

[IF NEEDED: An antibody test looks at someone’s
blood to see if they have ever been infected with
the coronavirus.]
[IF NEEDED: If [you/(SP)] have had more than one
antibody test to determine if [you/he/she] ever
had the coronavirus, think about your most
recent test.]
BOX A

IF P_PRIORCOVID=YES THEN GO TO CVEFFECT.
ELSE IF COVIDEV=YES OR SWABRSLT=01 OR
ANTRESLT=01 THEN GO TO CVDSVRE.

CVDSVRE

ELSE GO TO CVDEVHH.
How would you describe [your/(SP)’s] coronavirus
symptoms when they were at their worst? Would
you say [you/he/she] had no symptoms, mild
symptoms, moderate symptoms, or severe
symptoms?

20

2021 MCBS Community Questionnaire

Var Name

Question Text/Description

Response Options
(-7) REFUSED

Routing

CVDSEEK

Did [you/(SP)] seek medical care for coronavirus
or COVID-19?

CVDNOTRE

Why did [you/(SP)] not seek medical care?

(01) YES
(02) NO
(-8) DON'T KNOW
(-7) REFUSED
(01) YES
(02) NO
(-8) DON'T KNOW
(-7) REFUSED

(01) CVDHOSP
(02) CVDNOTRE
(-8) CVDHOSP
(-7) CVDHOSP
CVDHOSP

(01) YES
(02) NO
(-8) DON'T KNOW
(-7) REFUSED

NEXT QUESTION

READ EACH ITEM AND RECORD YES/NO
RESPONSE:

CVQ-COVID-19

CVDEXPEN. Was it too expensive?
CVDNTAVA. Was it not available?
CVDSYMNS. Were [your/his/her] symptoms not
severe enough?
CVDOTHER. Was there some other reason?
CVDHOSP

[Have you/Has (SP)] been hospitalized overnight
for coronavirus?
[IF NEEDED: This could include visiting the
emergency room or being admitted to the
hospital.]

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2021 MCBS Community Questionnaire

Var Name
CVEFFECT

Question Text/Description
(IF P_ FALLCOVID=YES DISPLAY:
The last time we spoke you told me [you/(SP)]
had been diagnosed with the coronavirus.)
Some people experience persistent symptoms of
coronavirus.

Response Options
(01) YES
(02) NO
(-8) DON'T KNOW
(-7) REFUSED

Routing
CVDEVHH

(01) YES
(02) NO
(03) R LIVES ALONE
(-8) DON'T KNOW
(-7) REFUSED

CVDVAC

CVQ-COVID-19

Did [you/(SP)] experience any of the following
symptoms for longer than 3 weeks after [you
were/he was/she was] first diagnosed with
coronavirus?
SMPTFATG. Fatigue
SMPTHEAD. Headaches
SMPTHRT. Chest pressure, heart palpitations, or
irregular heartbeats
SMPTACHE. Muscle aches
SMPTCOGH. Cough, shortness of breath, or other
respiratory symptoms
SMPTDIZZ. Dizziness or memory problems
SMPTANX. Anxiety
SMPTOTH. Any other symptoms?
CVDEVHH

Since (REFERENCE DATE), has a doctor or other
health professional (ever) told anyone living in
[your/(SP)’s] household that they have or likely
have coronavirus or COVID-19?
[IF NEEDED: A doctor or other health professional
might make this diagnosis based on a test for
COVID-19 or based on symptoms they have.]

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2021 MCBS Community Questionnaire

Var Name
CVDVAC

VACNUM

VACDAT1

VACDAT2

Question Text/Description
Since [DATE of COVID-19 vaccine availability]
[have you/has (SP)] had a coronavirus
vaccination?

Response Options
(01) YES
(02) NO
(-8) DON'T KNOW
(-7) REFUSED

DO NOT REPORT VACCINES THAT ARE SCHEDULED
FOR THE FUTURE. ONLY REPORT VACCINATIONS
THAT HAVE BEEN RECEIVED BY THE DATE OF THE
INTERVIEW.
How many coronavirus vaccination doses [have
(01) ONE VACCINATION DOSE
you/has (SP)] had?
(02) TWO VACCINATION DOSES
(-8) DON'T KNOW
IF NEEDED: Some vaccinations require two doses, (-7) REFUSED
given on separate days, in order to work properly.
DO NOT REPORT VACCINES THAT ARE SCHEDULED
FOR THE FUTURE. ONLY REPORT VACCINATIONS
THAT HAVE BEEN RECEIVED BY THE DATE OF THE
INTERVIEW.
When did [you/(SP)] receive the first dose of
MONTH (VACMON1)
coronavirus vaccination?
YEAR (VACYR1)
When did [you/(SP)] receive the second dose of
coronavirus vaccination?

MONTH (VACMON2)

Routing
(01) VACNUM
(02) NOVACRSN
(-8) DESCPRE1
(-7) DESCPRE1

CVQ-COVID-19

(01) VACDAT1
(02) VACDAT1
(-8) DESCPRE1
(-7) DESCPRE1

IF RESPONSE TO
VACNUM=(02) GO TO
VACDAT2. ELSE GO TO
DESCPRE1.
DESCPRE1

YEAR (VACYR2)

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2021 MCBS Community Questionnaire

NOVACRSN

For what reason didn’t [you/(SP)] get a
Coronavirus vaccine?
[PROBE: Any other reason?]
DO NOT READ ALOUD. CODE BASED ON WHAT
THE R SAYS.
CHECK ALL THAT APPLY.

(01) WAS SICK WITH COVID-19 SO
DOESN’T NEED THE VACCINE
(02) DIDN’T KNOW THE VACCINE WAS
NEEDED
(03) THE VACCINE COULD CAUSE COVID19
(04) THE VACCINE COULD HAVE SIDE
EFFECTS OR IS NOT SAFE
(05) DIDN’T THINK THE VACCINE WOULD
PREVENT COVID-19
(06) COVID-19 IS NOT SERIOUS
(07) DOCTOR DID NOT RECOMMEND
THE VACCINE
(08) DOCTOR RECOMMENDED AGAINST
GETTING THE VACCINE
(09) DON’T LIKE VACCINES OR NEEDLES
(10) COULDN’T GET TO THE PLACE
WHERE THEY WERE OFFERING THE
VACCINE
(11) COULDN’T FIND A PLACE THAT WAS
OFFERING THE VACCINE
(12) FORGOT
(13) COULD NOT AFFORD THE VACCINE
(14) HAD THE VACCINE BEFORE AND
DOESN’T NEED TO GET IT AGAIN
(15) THE VACCINE WAS NOT AVAILABLE
(16) THE VACCINE IS NOT WORTH THE
MONEY
(17) DIDN’T HAVE TIME TO GET THE
VACCINE
(18) NOT IN HIGH RISK/PRIORITY GROUP
(19) ONGOING HEALTH
CONDITION/ALLERGY/MEDICAL REASON

CVQ-COVID-19

(01)-(20), (-8), (-7)
DESCPRE1
(91) NOVCRNOS

24

2021 MCBS Community Questionnaire

Var Name

Question Text/Description

NOVCRNOS
DESCPRE1

OTHER (SPECIFY)
Since (REFERENCE DATE), [have you/has (SP)]
done any of the following in response to the
outbreak of the new coronavirus?
READ EACH ITEM AND RECORD YES/NO
RESPONSE:

Response Options
WHICH PREVENTS GETTING THE
VACCINE
(20) DON’T TRUST WHAT GOVERNMENT
SAYS ABOUT VACCINE
(91) OTHER
(-8) DON’T KNOW
(-7) REFUSED
Verbatim text box
(01) YES
(02) NO
(03) UNABLE DUE TO SHORTAGES
(04) NOT APPLICABLE
(-8) DON'T KNOW
(-7) REFUSED

Routing

CVQ-COVID-19

DESCPRE1
NEXT QUESTION

(01)PREVWASH. Washed [your/his/her] hands
for 20 seconds with soap and water
(02)PREVSANI. Used hand sanitizer
(03)PREVFACE. Avoided touching
[your/his/her] face
(04)PREVTISS. Coughed or sneezed into a
tissue or sleeve
(05)PREVMASK. Worn a facemask when out in
public

25

2021 MCBS Community Questionnaire

Var Name
DESCPRE2

Question Text/Description
[Since (REFERENCE DATE) [have you/has (SP)]
done any of the following in response to the
outbreak of the new coronavirus?]
READ EACH ITEM AND RECORD YES/NO
RESPONSE:

Response Options
(01) YES
(02) NO
(04) NOT APPLICABLE
(-8) DON'T KNOW
(-7) REFUSED

Routing
NEXT QUESTION

CVQ-COVID-19

(01)PREVCLEA. Cleaned or sterilized
commonly-touched surfaces, such as door
knobs
(02)PREVCONT. Avoided contact with sick
people
(03)PREVDIST. Kept a six-foot distance
between [yourself/himself/herself] and
people outside [your/his/her] household
(04)PREVGRP. Avoided large groups of people
(05)PREVSHEL. Left [your/his/her] home for
essential purposes only, such as for
medical appointments or grocery
shopping, sometimes called “sheltering in
place”

26

2021 MCBS Community Questionnaire

Var Name
DESCPRE3

Question Text/Description
[Since (REFERENCE DATE) [have you/has (SP)]
done any of the following in response to the
outbreak of the new coronavirus?]
READ EACH ITEM AND RECORD YES/NO
RESPONSE:

DESC_INF

(01) PREVFOOD. Purchased extra food
(02) PREVSUPP. Purchased extra cleaning
supplies
(03) PREVMEDI. Purchased or picked up extra
prescription medicines beyond
[your/his/her] usual purchases
(04) PREVCONS. Consulted with a health care
provider about coronavirus
(05) PREVPPL. Avoided other people as much
as possible
What sources [do you/does (SP)] rely on for
information about the coronavirus? For each
source I read, please tell me yes or no.

Response Options
(01) YES
(02) NO
(03) UNABLE DUE TO SHORTAGES
(04) NOT APPLICABLE
(-8) DON'T KNOW
(-7) REFUSED

Routing
NEXT QUESTION

CONTINUE

NEXT QUESTION

CVQ-COVID-19

CLICK NEXT FOR SOURCES

27

2021 MCBS Community Questionnaire

Var Name
INFOSORC1

Question Text/Description
[What sources [do you/does (SP)] 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:

CVQ-COVID-19

Response Options
(01) YES
(02) NO
(-8) DON'T KNOW
(-7) REFUSED

Routing
NEXT QUESTION

(01) YES
(02) NO
(-8) DON'T KNOW
(-7) REFUSED

IF INFOSUM IS
GREATER THAN OR
EQUAL TO 2 THEN GO
TO INFOMOST.

INFONEWS. Traditional news sources, including
on TV, radio, websites, and newspapers
INFOSOCI. Social media
INFOGOVT. Comments or guidance from
government officials
INFOSORC2

What sources [do you/does (SP)] 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:
INFOINT. Other webpages/internet
INFOFRIE. Friends or family members
INFOHCPR. Health care providers

ELSE IF INFOSUM=1
THEN SET
INFOMOST=THE
VARIABLE THAT HAD
THE YES RESPONSE.
ELSE IF SPPROXY=01
GO TO CVDAGREE.
ELSE GO TO RECCDC.

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2021 MCBS Community Questionnaire

Var Name
INFOMOST

CVDAGREE

Question Text/Description
You said [you rely/(SP) relies] on [DISPLAY ALL
ITEMS FOR WHICH RESPONSE TO INFOSORC1 OR
INFOSORC2 WAS YES] for information about the
coronavirus. Which of these sources [do you/does
he/does she] rely on most?
For each of the following statements, please rate
whether you strongly agree, agree, neither agree
nor disagree, disagree, or strongly disagree:
CONTAG. Coronavirus is more contagious than
the flu.
DEADLY. Coronavirus is more deadly than the flu.

GETVAC

TAKECAUT. It is important for everyone to take
precautions to prevent the spread of the
Coronavirus, even if they are not in a high-risk
group (e.g., elderly, chronically ill).
If a vaccine that protected you from Coronavirus
was available to everyone who wanted it, would
you get it? Definitely, probably, probably not,
definitely not, or are you not sure?

Response Options
DISPLAY ALL ITEMS FOR WHICH
RESPONSE TO INFOSORC1 OR
INFOSORC2 WAS “YES”.
(-8) DON'T KNOW
(-7) REFUSED
(01) STRONGLY AGREE
(02) AGREE
(03) NEITHER AGREE NOR DISAGREE
(04) DISAGREE
(05) STRONGLY DISAGREE
(-8) DON'T KNOW
(-7) REFUSED

(01) DEFINITELY
(02) PROBABLY
(03) PROBABLY NOT
(04) DEFINITELY NOT
(05) NOT SURE
(-7) REFUSED

CVQ-COVID-19

Routing
IF SPPROXIN=01 GO
TO CVDAGREE.
IF SPPROXIN=02 GO
TO DISRUPT.
NEXT QUESTION

(01) RECCDC
(02) RECCDC
(03) NOGETVAC
(04) NOGETVAC
(05) RECCDC
(-7) RECCDC

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2021 MCBS Community Questionnaire

Var Name
NOGETVAC

Question Text/Description
For what reason would you not get a Coronavirus
vaccine?
[PROBE: Any other reason?]
DO NOT READ ALOUD. CODE BASED ON WHAT
THE R SAYS.

NOGETCOS

OTHER (SPECIFY)

CVQ-COVID-19

Response Options
(01) THE VACCINE COULD CAUSE COVID19
(02) THE VACCINE COULD HAVE SIDE
EFFECTS OR IS NOT SAFE
(03) DOESN’T THINK THE VACCINE
WOULD PREVENT COVID-19
(04) COVID-19 IS NOT SERIOUS
(05) DOESN’T LIKE VACCINES OR
NEEDLES
(06) DOESN’T HAVE TIME TO GET THE
VACCINE
(07) NOT IN HIGH RISK/PRIORITY GROUP
(08) ONGOING HEALTH
CONDITION/ALLERGY/MEDICAL REASON
WHICH PREVENTS GETTING THE
VACCINE
(09) DOESN’T TRUST WHAT
GOVERNMENT SAYS ABOUT VACCINE
(91) OTHER
(-8) DON’T KNOW
(-7) REFUSED

Routing
(01)-(10), (-8), (-7)
RECCDC

Verbatim text box

RECCDC

(91) NOGETCOS

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2021 MCBS Community Questionnaire

RECCDC

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?
[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
(-7) REFUSED

NEXT QUESTION

CVQ-COVID-19

RECWASH. Frequent hand washing
RECMASK. Healthy people wearing facemasks in
public
RECAVOI. Avoiding gatherings with groups of 10
or more people
RECSTAY. Staying home except for essential
activities such as grocery shopping or medical
care (shelter in place)
RECMEDI. Seeking medical attention if you are
having trouble breathing

31

2021 MCBS Community Questionnaire

DISRUPT

Since (REFERENCE DATE), [have you/has (SP)]
been able, unable, or have not needed…
DISRRENT. To pay rent or [your/his/her]
mortgage?

(01) ABLE
(02) UNABLE
(03) HAVE NOT NEEDED
(-8) DON’T KNOW
(-7) REFUSED

BOX C

CVQ-COVID-19

IF THE RESPONDENT OWNS THEIR HOME
OUTRIGHT AND/OR DOESN’T NEED TO PAY RENT
OR MORTGAGE, SELECT “HAVE NOT NEEDED”.
DISRMEDI. To get medications?
DISRAPPT. To get a doctor’s appointment or some
other kind of healthcare?
DISRFOOD. To get the food [you want/he
wants/she wants]?
DISRSUPP. To get household supplies, such as
toilet paper?
DISRMASK. To get face masks?

BOX C

IF RESPONDENT WANTED TO GET HOUSEHOLD
SUPPLIES BUT WAS NOT ABLE TO BECAUSE OF
SUPPLY SHORTAGES, SELECT “UNABLE”.
IF SPPROXIN=01 GO TO FEELFINC.
ELSE IF SPPROXIN=02 GO TO THANKYOU.

32

2021 MCBS Community Questionnaire

FEELFINC

Since (REFERENCE DATE)…
Have you felt more financially secure, less
financially secure, or about the same?

FEELANXI

[Since (REFERENCE DATE)…]
have you felt more stressed or anxious, less
stressed or anxious, or about the same?

FEELDEPR

[Since (REFERENCE DATE) …]
have you felt more lonely or sad, less lonely or
sad, or about the same?

FEELSOCI

[Since (REFERENCE DATE)…]
have you felt more socially connected to family
and friends, less socially connected to family and
friends, or about the same?

THANKYOU

Thank you for participating in this important
survey.

(01) MORE FINANCIALLY SECURE
(02) LESS FINANCIALLY SECURE
(03) ABOUT THE SAME
(-8) DON’T KNOW
(-7) REFUSED
(01) MORE STRESSED OR ANXIOUS
(02) LESS STRESSED OR ANXIOUS
(03) ABOUT THE SAME
(-8) DON’T KNOW
(-7) REFUSED
(01) MORE LONELY OR SAD
(02) LESS LONELY OR SAD
(03) ABOUT THE SAME
(-8) DON’T KNOW
(-7) REFUSED
(01) MORE SOCIALLY CONNECTED
(02) LESS SOCIALLY CONNECTED
(03) ABOUT THE SAME
(-8) DON’T KNOW
(-7) REFUSED

NEXT QUESTION

(01) CONTINUE

NEXT QUESTION

CVQ-COVID-19

NEXT QUESTION

NEXT QUESTION

NEXT QUESTION

(IF ACOFLAG=02 (NO) DISPLAY: AFTER THANKING
THE RESPONDENT, YOU MAY PROVIDE THEM
WITH AN UPDATE ON WHEN YOU WILL NEXT BE
IN CONTACT WITH THEM.)
END

IT IS NOW SAFE TO CLOSE YOUR BROWSER.

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