P-0015A COVID-19 Questionnaire Specifications

2023 MCBS Community Questionnaire

Variable Name

MR Screen Name Question Type

CVQ-COVID-19

Question Text/Description

Code List

Routing

(01) YES
(02) NO
(-8) DON'T KNOW
(-7) REFUSED
(01) FEVER
(02) ONGOING DRY COUGH
(03) RUNNY NOSE
(04) SNEEZING
(05) SHORTNESS OF BREATH
(06) HEADACHE
(07) SORE THROAT
(08) NAUSEA
(09) VOMITING
(10) EXTREME FATIGUE
(11) CHILLS/REPEATED SHAKING WITH CHILLS
(12) MUSCLE PAIN
(13) NEW LOSS OF TASTE OR SMELL
(14) LOSS OF APPETITE
(15) DIARRHEA
(91) OTHER
(-8) DON'T KNOW
(-7) REFUSED

(01) SUSPECTY
(02) COVIDEV
(-8) COVIDEV
(-7) COVIDEV

COVID-19 QUESTIONNAIRE SPECIFICATIONS
CRITERIA
INTTYPE=ALL
SPALIVE=1
SEASON=ALL
SPPROXY=SP or PROXY
Other: N/A
PLACEMENT
Administer after PVQ

SUSPECT

SUSPECT

yes/no

SUSPECTY

SUSPECTY

code all

Since April 1, 2021, [have you/has (SP)] suspected that [you have/he has/she has] had the coronavirus or COVID19?

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

COVIDEV

COVIDEV

yes/no

Since April 1, 2021, has a doctor or other health professional told [you/(SP)] that [you have/he has/she has] or likely (01) YES
had coronavirus or COVID-19?
(02) NO
(-8) DON'T KNOW
[IF NEEDED: A doctor or other health professional might make this diagnosis based on a test for COVID-19 or
(-7) REFUSED
based on symptoms [you have/(SP)] has].

COVIDEV

COVSWAB

Since April 1, 2021, [have you/has(SP)] been tested to see whether [you were/he was/she was] infected with
coronavirus or COVID-19 at the time of the test?
(01) YES
(02) NO
(-8) DON'T KNOW
[IF NEEDED: If [you have/(SP) has] had more than one test to see whether [you were/he was/she was] infected with
(-7) REFUSED
coronavirus or COVID-19 at the time of the test, think about [your/his/her] most recent test.]
[IF NEEDED: For example, the test can be done by swabbing [your/his/her] nose or mouth.]
COVSWAB

COVSWAB

yes/no

(01) SWABRSLT
(02) BOX CV1A
(-8) BOX CV1A
(-7) BOX CV1A

DO NOT INCLUDE ANTIBODY TESTS, WHICH TEST WHETHER SOMEONE HAS EVER BEEN INFECTED
WITH CORONAVIRUS.
Did the test find that [you/(SP)] had coronavirus or COVID-19?

SWABRSLT

SWABRSLT

code one

(01) YES, THE TEST SHOWED R HAD COVID-19
(01) SWABWAIT
(02) NO, THE TEST SHOWED R DID NOT HAVE COVID- (02) SWABWAIT
[IF NEEDED: If [you have/(SP) has] had more than one test to see whether [you were/he was/she was] infected with
19
(03) CVTSTPAY
coronavirus or COVID-19 at the time of the test, think about [your/his/her] most recent test.]
(03) NO RESULTS YET
(-8) CVTSTPAY
(-8) DON’T KNOW
(-9) CVTSTPAY
DO NOT INCLUDE ANTIBODY TESTS, WHICH TEST WHETHER SOMEONE HAS EVER BEEN INFECTED
(-7) REFUSED
WITH CORONAVIRUS.
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 7 days or more?

SWABWAIT

SWABWAIT

code one

(01) SAME DAY
(02) NEXT DAY
(03) 2-3 DAYS
[IF NEEDED: If [you have/(SP) has] had more than one test to see whether [you were/he was/she was] infected with
(04) 4-6 DAYS
coronavirus or COVID-19 at the time of the test, think about [your/his/her] most recent test.]
(05) 7 DAYS OR MORE
(-8) DON’T KNOW
DO NOT INCLUDE ANTIBODY TESTS, WHICH TEST WHETHER SOMEONE HAS EVER BEEN INFECTED
(-7) REFUSED
WITH CORONAVIRUS.

CVTSTPAY

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2023 MCBS Community Questionnaire

Variable Name

MR Screen Name Question Type

CVQ-COVID-19

Question Text/Description

Code List

Routing

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.]
CVTSTPAY

(01) NONE OF THE COST
(02) PART OF THE COST
[IF NEEDED: If [you have/(SP) has] had more than one test to see whether [you were/he was/she was] infected with (03) ALL OF THE COST
coronavirus or COVID-19 at the time of the test, think about [your/his/her] most recent test.]
(-8) DON'T KNOW
(-7) REFUSED
DO NOT INCLUDE ANTIBODY TESTS, WHICH TEST WHETHER SOMEONE HAS EVER BEEN INFECTED
WITH CORONAVIRUS.

CVTSTPAY

code one

BOX CV1A

routing

IF COVIDEV=YES OR SWABRSLT=01 THEN GO TO CVDSVRE.
ELSE GO TO VACROST.
(01) NO SYMPTOMS
(02) MILD SYMPTOMS
(03) MODERATE SYMPTOMS
(04) SEVERE SYMPTOMS
(-8) DON'T KNOW
(-7) REFUSED

CVDSEEK

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

(01) CVDHOSP
(02) CVDEXPEN-CV1
(-8) CVDHOSP
(-7) CVDHOSP

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

CVDNTAVA-CV1

CVDSVRE

CVDSVRE

code one

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?

CVDSEEK

CVDSEEK

yes/no

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

CVDEXPEN

CV1

grid

Why did [you/(SP)] not seek medical care?
READ EACH ITEM AND RECORD YES/NO RESPONSE:
Was it too expensive?
CVDNTAVA

CV1

grid

Was it not available?

CVDSYMNS

CV1

grid

Were [your/(SP)'s] symptoms not severe enough?

CVDOTHER

CV1

grid

Was there some other reason?

CVDHOSP

CVDHOSP

yes/no

[Have you/Has (SP)] 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
(-7) REFUSED
(01) YES
(02) NO
(-8) DON'T KNOW
(-7) REFUSED
(01) YES
(02) NO
(-8) DON'T KNOW
(-7) REFUSED
(01) YES
(02) NO
(-8) DON'T KNOW
(-7) REFUSED

BOX CV1A

CVDSYMNS-CV1

CVDOTHER-CV1

CVDHOSP

LONGCVD

Did [you/(sp)] have any symptoms lasting 3 months or longer that [you/(sp)] did not have prior to having coronavirus
or COVID-19?
LONGCVD

VACROST

LONGCVD

VACROST

yes/no

roster

(01) YES
(02) NO
[IF NEEDED: Long term symptoms may include tiredness or fatigue, difficulty thinking, concentrating, forgetfulness
(-8) DON'T KNOW
or memory problems, sometimes referred to as "brain fog," difficulty breathing or shortness of breath, joint or
(-7) REFUSED
muscle pain, fast-beating or pounding heart (also known as heart palpitations), chest pain, dizziness on standing,
depression, anxiety or mood changes.]
(01) YES
(02) NO
[IF NEEDED: You previously reported the following COVID-19 vaccines.] Since [December 2020/(REFERENCE
(-8) DON'T KNOW
DATE)], [have you/has (SP)] received any [additional] doses of a COVID-19 vaccine?
(-9) REFUSED

VACROST

(01) VACDAT-VACDATMM
(02) BOX CV2
(-8) BOX CVEND
(-9) BOX CVEND

When did [you/(SP)] receive this dose of the COVID-19 vaccine?

VACDATMM

VACDAT

date

IF NEEDED: [You/(SP)] may have been given a “COVID-19 Vaccination Record Card” with this information on it. It
could be helpful to refer to that card if it is available.

MONTH (VACMON)

VACDAT-VACDATYY

PLEASE ENTER COVID-19 VACCINE DOSES IN THE ORDER THEY WERE RECEIVED, STARTING FROM THE
EARLIEST DOSE RECEIVED TO THE MOST RECENT DOSE RECEIVED.
When did [you/(SP)] receive this dose of the COVID-19 vaccine?
VACDATYY

VACDAT

date

YEAR (VACYR)
IF NEEDED: [You/(SP)] may have been given a “COVID-19 Vaccination Record Card” with this information on it. It
could be helpful to refer to that card if it is available.

VACNME

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2023 MCBS Community Questionnaire

Variable Name

MR Screen Name Question Type

CVQ-COVID-19

Question Text/Description
Which COVID-19 vaccine did (you/(SP)) get? Examples include Pfizer-BioNTech/Comirnaty, Moderna/Spikevax,
and Johnson & Johnson/Janssen.

VACNME

VACNME

code one

VACNMEOS

VACNMEOS

text

IF NEEDED: [You/(SP)] may have been given a “COVID-19 Vaccination Record Card” with this information on it. It
could be helpful to refer to that card if it is available.
ONLY USE THE ‘OTHER’ CATEGORY TO ADD VACCINE MANUFACTURERS APPROVED IN AN FI MEMO
OTHER (SPECIFY)

Where did [you/(SP)] go for this dose of the COVID-19 vaccine?
VACSITE

VACSITE

code one

VACSITOS

VACSITOS

text

A MASS VACCINATION SITE IS A LOCATION THAT WAS SET UP ESPECIALLY TO ADMINISTER COVID-19
VACCINES, OFTEN ORGANIZED BY A LOCAL, STATE, OR FEDERAL AGENCY. MASS VACCINATION SITES
MAY BE LOCATED AT A SHOPPING CENTER, CONVENTION CENTER, SPORTING FACILITY, CHURCH,
LIBRARY, HOSPITAL OR OTHER COMMUNITY LOCATION.

OTHER (SPECIFY)

Code List

Routing

(01) PFIZER-BIONTECH/COMIRNATY
(02) MODERNA/SPIKEVAX
(03) JOHNSON & JOHNSON/JANSSEN
(91) OTHER
(-8) DON'T KNOW
(-9) REFUSED

(01)-(03), (-8), (-9) VACSITE
(91) VACNMEOS

(01) CONTINUOUS ANSWER
(01) FACILITY ONLY- FACILITY NAME (DO NOT
DISPLAY)
(02) PHARMACY/DRUG STORE
(03) DOCTORS OFFICE OR GROUP PRACTICE
(04) MASS VACCINATION SITE
(05) MANAGED CARE PLAN CENTER/HMO
(06) NEIGHBORHOOD/FAMILY HEALTH
CENTER/MEDICAL CLINIC
(07) COMPANY CLINIC/WORKPLACE
(08) WALK-IN URGENT CENTER
(09) HOSPITAL
(10) VA FACILITY
(11) HEALTH DEPARTMENT OFFICE
(12) AT HOME
(91) OTHER, SPECIFY
(-8) DON’T KNOW
(-9) REFUSED
(01) CONTINUOUS ANSWER

Since [December 2020/(REFERENCE DATE)], [have you/has (SP)] had any other COVID-19 vaccine doses?
VACMOR

PRSUMVAC

VACMOR

yes/no

(01) YES
(02) NO
PLEASE ENTER COVID-19 VACCINE DOSES IN THE ORDER THEY WERE RECEIVED, STARTING FROM THE (-8) DON'T KNOW
EARLIEST DOSE RECEIVED TO THE MOST RECENT DOSE RECEIVED.
(-9) REFUSED

BOX CV2

routing

IF NO VACCINE DOSES IN THE ROSTER, GO TO PRSUMVAC,
ELSE IF AT LEAST ONE DOSE IN ROSTER AND VACROST=02/NO, GO TO NOVACRSN.
ELSE GO TO BOX CVEND.

PRSUMVAC

code one

Now that a vaccine to prevent COVID-19 is available to most adults in the United States, will [you/(SP)] get it?
Definitely, probably, probably not, definitely not, or are you not sure?

For what reason didn’t [you/(SP)] get a COVID-19 vaccine [since (REFERENCE DATE)])?
[PROBE: Any other reason?]
NOVACRSN

NOVACRSN

code all

DO NOT READ ALOUD. CODE BASED ON WHAT THE RESPONDENT SAYS.
CHECK ALL THAT APPLY.

(01) DEFINITELY
(02) PROBABLY
(03) PROBABLY NOT
(04) DEFINITELY NOT
(05) NOT SURE
(-9) REFUSED

VACSITE

(01)-(12), (-8), (-9) VACMOR
(91) VACSITOS

VACMOR
(01) VACDAT-VACDATMM
(02) PREVMASK
(-8) PREVMASK
(-9) PREVMASK

NOVACRSN

(01) CONCERNED ABOUT POSSIBLE SIDE EFFECTS
OF A COVID-19 VACCINE
(02) CONCERNED ABOUT HAVING AN ALLERGIC
REACTION
(03) DOESN'T KNOW IF A COVID-19 VACCINE WILL
PROTECT THEM
(04) DOESN’T BELIEVE THEY NEED A COVID-19
VACCINE
(05) ALREADY HAD COVID-19
(06) DOES NOT SPEND TIME WITH ANY HIGH-RISK
PEOPLE
(07) PLANS TO USE MASKS OR OTHER
PRECAUTIONS INSTEAD
(08) DOESN'T THINK VACCINES ARE BENEFICIAL
(09) THINKS IMMUNE SYSTEM IS STRONG ENOUGH
(10) DOCTOR HAS NOT RECOMMENDED IT
(11) PLANS TO WAIT AND SEE IF IT IS SAFE AND
MAY GET IT LATER
(01)-(20); (-8), (-9) BOX CVEND
(12) CONCERNED ABOUT THE COST OF A COVID-19 (91) NOVCRNOS
VACCINE
(13) DOESN'T TRUST COVID-19 VACCINES
(14) DOESN’T THINK COVID-19 IS THAT BIG OF A
THREAT
(15) HARD TO GET A COVID-19 VACCINE
(16) FAMILY AND FRIENDS ARE CHOOSING NOT TO
GET A COVID-19 VACCINE
(17) AFRAID OF NEEDLES
(18) CAN’T GET THE BRAND OF VACCINE THAT THEY
PREFER
(19) APPOINTMENT SCHEDULED
(20) HAS A HEALTH OR MEDICAL CONDITION WHICH
PREVENTS GETTING THE VACCINE
(91) OTHER
(-8) DON’T KNOW
(-9) REFUSED

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CHECK ALL THAT APPLY.

2023 MCBS Community Questionnaire

Variable Name

MR Screen Name Question Type

Question Text/Description

NOVCRNOS

NOVCRNOS

verbatim

BOX CVEND

routing

OTHER (SPECIFY)
IF SEASON=FALL, GO TO HFQ.
ELSE IF SEASON=WINTER, GO TO KNQ.
ELSE IF SEASON=SUMMER AND RESPONDENT=SP, GO TO CPQ.
ELSE IF SEASON=SUMMER AND RESPONDENT=PROXY, GO TO IAQ.

(13) DOESN'T TRUST COVID-19 VACCINES
(14) DOESN’T THINK COVID-19 IS THAT BIG OF A
THREAT
(15) HARD TO GET A COVID-19 VACCINE
(16) FAMILY AND FRIENDS ARE CHOOSING NOT TO
GET A COVID-19 VACCINE
(17) AFRAID OF NEEDLES
(18) CAN’T GET THE BRAND OF VACCINE THAT THEY
PREFER
Code
List
Routing
(19) APPOINTMENT
SCHEDULED
(20) HAS A HEALTH OR MEDICAL CONDITION WHICH
PREVENTS GETTING THE VACCINE
(91) OTHER
(-8) DON’T KNOW
(-9) REFUSED

(01) CONTINUOUS ANSWER

CVQ-COVID-19

BOX CVEND

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