Attachment 1a
CoVID-19 – COQ
Target Group: SPs Birth +
COQ.010 {Have you/Has SP} ever had COVID-19, or the illness caused by the Coronavirus Disease 2019?
INTERVIEWER INSTRUCTIONS:
CODE ‘MAYBE’ IF THE SP THINKS S/HE MAY HAVE HAD COVID-19 DUE TO EXPERIENCING CERTAIN SYMPTOMS BUT DID NOT GET TESTED OR IS UNSURE OF THE RESULTS. CODE ‘DON’T KNOW’ IF THE SP DOES NOT KNOW IF S/HE HAS HAD COVID-19.
YES 1
NO 2 (COQ.030)
MAYBE 3
REFUSED 7 (COQ.030)
DON’T KNOW 9 (COQ.030)
COQ.020 How would {you/SP’s} describe {your/his/her} symptoms when they were at their worst? Would you say…
No symptoms 1
Mild symptoms 2
Moderate symptoms 3
Severe symptoms 4
REFUSED 7
DON’T KNOW 9
COQ.030 Now I’m going to ask you about testing for active COVID infections, which is done through a nasal or throat swab or a saliva test. This does not include blood tests for COVID-19.
{Have you/Has SP} ever been tested for coronavirus or COVID-19?
YES 1
NO 2 (COQ.060)
REFUSED 7 (COQ.060)
DON’T KNOW 9 (COQ.060)
COQ.040 Did the swab or saliva test find that {you/SP} had coronavirus or COVID-19?
INTERVIEWER INSTRUCTION: IF TESTED MULTIPLE TIMES, CODE ANY POSITIVE RESULT RECEIVED AS YES.
YES 1
NO 2 (COQ.060)
DID NOT RECEIVE RESULTS 3 (COQ.060)
REFUSED 7 (COQ.060)
DON’T KNOW 9 (COQ.060)
COQ.050m/y What was the date of {your/SP’s} positive COVID-19 test? Please tell me the month and year of {your/his/her} most recent positive test. This does not include the blood test.
INTERVIEWER INSTRUCTION: PROBE FOR ANY MISSING PORTIONS OF DATE.
|___|___|
ENTER MONTH
REFUSED 77
DON'T KNOW 99
|___|___|___|___|
ENTER YEAR
REFUSED 7777
DON'T KNOW 9999
CAPI INSTRUCTIONS:
HARD EDIT VALUE FOR MONTH: 01-12
HARD EDIT: DATE MUST BE CURRENT MONTH AND YEAR OR PRIOR.
HARD EDIT: YEAR MUST BE 2020 OR LATER.
COQ.060 {Have you/Has SP} ever had an antibody blood test to determine if {you/s/he} had coronavirus or COVID-19 in the past?
INTERVIEWER INSTRUCTION: IF TESTED MULTIPLE TIMES, CODE ANY POSITIVE RESULT RECEIVED AS YES.
YES 1
NO 2 (COQ.080)
REFUSED 7 (COQ.080)
DON’T KNOW 9 (COQ.080)
COQ.070 Did the blood test find that {you/SP} had antibodies for coronavirus or COVID-19?
YES 1
NO 2 (COQ.080)
DID NOT RECEIVE RESULTS 3 (COQ.080)
REFUSED 7 (COQ.080)
DON’T KNOW 9 (COQ.080)
COQ.075m/y What was the date of this blood test? Please tell me the month and year of the most recent date that the blood test found {you/SP} had antibodies for COVID-19?
INTERVIEWER INSTRUCTION: PROBE FOR ANY MISSING PORTIONS OF DATE.
|___|___|
ENTER MONTH
REFUSED 77
DON'T KNOW 99
|___|___|___|___|
ENTER YEAR
REFUSED 7777
DON'T KNOW 9999
CAPI INSTRUCTIONS:
HARD EDIT VALUE FOR MONTH: 01-12
HARD EDIT: DATE MUST BE CURRENT MONTH AND YEAR OR PRIOR.
HARD EDIT: YEAR MUST BE 2020 OR LATER.
COQ.080 {Have you/Has SP} ever received a vaccine for COVID-19?
YES 1
NO 2 (COQ.100)
REFUSED 7 (COQ.100)
DON’T KNOW 9 (COQ.100)
COQ.086 How many doses of COVID-19 vaccine {have you/has he/has she} received? Please include booster shots and any additional doses.
INTERVIEWER INSTRUCTION:
IF THE RESPONDENT WAS HESITATING OR NOT SURE ABOUT THE ANSWER, ENCOURAGE THE RESPONDENT TO GET THE VACCINE CARD OR CHECK THE VACCINATION RECORD TO HELP ANSWERING THE QUESTION.
|___|___|
ENTER THE NUMBER OF DOSES
REFUSED 77
DON'T KNOW 99
BOX 1
LOOP 1:
ASK COQ.087 FOR EACH VACCINE
COQ.087/088 Which COVID-19 vaccine did {you/SP} receive {for your first/second/third/fourth/… dose}? Is it Johnson & Johnson, Moderna, Pfizer-BioNTech, or something else?
INTERVIEWER INSTRUCTION:
IF THE RESPONDENT WAS HESITATING OR NOT SURE ABOUT THE ANSWER, ENCOURAGE THE RESPONDENT TO GET THE VACCINE CARD OR CHECK THE VACCINATION RECORD TO HELP ANSWERING THE QUESTION.
VACCINE |
BRAND |
1st Dose |
|
2nd Dose |
|
3rd Dose |
|
… |
|
JOHNSON & JOHNSON (JANSSEN) 1
MODERNA 2
PFIZER-BIONTECH 3
OTHER (SPECIFIED_________) 4
REFUSED 7
DON’T KNOW 9
CAPI INSTRUCTION:
DISPLAY A VACCINE ROSTER WITH NUMBER OF VACCINES INDICATED IN COQ.086 (SEE EXAMPLE GRID ABOVE).
IF COQ.086 = (77 OR 99), DISPLAY ONE ROW (1ST DOSE) IN THE GRID.
DISPLAY “for your first/second/third/fourth/… dose” BASED ON THE DOSE NUMBER, IF 1 < COQ.086 AND COQ.086 ≠ (77 OR 99).
ALLOW ENTRY OF VACCINE BRAND USING DROP-DOWN LIST FOR EACH DOSE.
ALLOW INTERVIEWER TO ADD ROW(S) IF ADDITIONAL DOSE(S) REPORTED.
IF CODE 4 (OTHER) IS SELECTED, ACTIVATE A TEXT FIELD (COQ.088) TO ALLOW SPECIFYING OTHER VACCINE BRAND USING A DROP-DOWN LIST WITH TYPING IN “NOT LISTED” OPTION AVAILABLE.
BOX 2
END LOOP 1:
ASK COQ.087 FOR THE NEXT VACCINE.
IF INFORMATION COLLECTED FOR ALL VACCINES, GO TO BOX 3
BOX 3
LOOP 2:
ASK COQ.095M/Y FOR EACH VACCINE.
COQ.095m/y In what month and year did {you/he/she} receive the {first/second/third/fourth/… dose of} vaccine for COVID-19?
INTERVIEWER INSTRUCTION:
IF THE RESPONDENT WAS HESITATING OR NOT SURE ABOUT THE ANSWER, ENCOURAGE THE RESPONDENT TO GET THE VACCINE CARD OR CHECK THE VACCINATION RECORD TO HELP ANSWERING THE QUESTION.
PROBE FOR ANY MISSING PORTIONS OF DATE.
REVIEW THE ENTRIES WITH THE RESPONDENT ONCE THE ENTIRE GRID IS COMPLETED.
VACCINE |
BRAND |
DATE |
|
MONTH |
YEAR |
||
1st Dose |
Brand reported in COQ.087 |
|
|
2nd Dose |
Brand reported in COQ.087 |
|
|
3rd Dose |
Brand reported in COQ.087 |
|
|
… |
|
|
|
|___|___|
ENTER MONTH
REFUSED 77
DON'T KNOW 99
|___|___|___|___|
ENTER YEAR
REFUSED 7777
DON'T KNOW 9999
CAPI INSTRUCTIONS:
ADD THE DATE (MONTH/YEAR) ENTRY FIELDS TO THE GRID IN COQ.087 SO THE DATES CAN BE VIEWED NEXT TO THE CORRESPONDING DOSE AND BRAND FIELDS.
HARD EDIT VALUE FOR MONTH: 01-12
HARD EDIT: DATE MUST BE CURRENT MONTH AND YEAR OR PRIOR.
HARD EDIT: YEAR MUST BE 2020 OR LATER.
SOFT EDIT: IF DATE ENTERED IS BEFORE NOVEMBER 2020, DISPLAY A MESSAGE AND ASK INTREVIEWER TO VERIFY.
DISPLAY “first/second/third/fourth/… dose of” IF MORE THAN 1 ROW ENTERED IN COQ.087.
BOX 4
END LOOP 1:
ASK COQ.095M/Y FOR THE NEXT VACCINE.
IF INFORMATION COLLECTED FOR ALL VACCINES, CONTINUE TO COQ.100.
COQ.100 {Have you/Has SP} ever had an overnight stay in a hospital for suspected or confirmed COVID-19?
YES 1
NO 2
REFUSED 7
DON’T KNOW 9
COQ.110 Has anyone else in {your/SP’s} household ever tested positive for coronavirus or COVID-19?
YES 1
NO 2
REFUSED 7
DON’T KNOW 9
HELP SCREEN:
Household: The entire group of persons who live in one dwelling unit. It may be several persons living together or one person living alone. It includes the household reference person and any of their relatives, as well as roomers, employees, and other non-related persons.
COQ.120 {Do you/Does SP} currently have a health condition that a doctor or other health professional told {you/him/her} weakens the immune system, making it easier for {you/him/her} to get sick?
YES 1
NO 2
REFUSED 7
DON’T KNOW 9
HELP SCREEN:
Doctor: The term refers to both doctors of medicine (M.D.s) and doctors of osteopathic medicine (D.O.s). It includes general practitioners as well as specialists. It does not include persons who do not have an M.D. or D.O. degree, but other doctoral degrees such as dentists, oral surgeons, chiropractors, podiatrists, Christian Science healers, opticians, optometrists, psychologists, etc.
Health Care Professionals (Health Professional): A person entitled by training and experience and possibly licensure to assist a doctor and who works with one or more medical doctors. Examples include: doctor’s assistants, nurse practitioners, nurses, pharmacists, lab technicians, and technicians who administer shots (e.g., allergy shots). Also include paramedics, medics and physical therapists working with or in a doctor’s office. Do not include: dentists, oral surgeons, chiropractors, chiropodists, podiatrists, naturopaths, Christian Science healers, opticians, optometrists, and psychologists or social workers.
COQ.130 In the past 12 months, {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?
YES 1
NO 2
REFUSED 7
DON’T KNOW 9
HELP SCREEN:
Doctor: The term refers to both doctors of medicine (M.D.s) and doctors of osteopathic medicine (D.O.s). It includes general practitioners as well as specialists. It does not include persons who do not have an M.D. or D.O. degree, but other doctoral degrees such as dentists, oral surgeons, chiropractors, podiatrists, Christian Science healers, opticians, optometrists, psychologists, etc.
Health Care Professionals (Health Professional): A person entitled by training and experience and possibly licensure to assist a doctor and who works with one or more medical doctors. Examples include: doctor’s assistants, nurse practitioners, nurses, pharmacists, lab technicians, and technicians who administer shots (e.g., allergy shots). Also include paramedics, medics and physical therapists working with or in a doctor’s office. Do not include: dentists, oral surgeons, chiropractors, chiropodists, podiatrists, naturopaths, Christian Science healers, opticians, optometrists, and psychologists or social workers.
COQ.140 There are two types of flu vaccinations. One is a shot and the other is a spray, mist, or drop in the nose. During the past 12 months, {have you/has SP} had a flu vaccination?
YES 1
NO 2
REFUSED 7
| File Type | application/vnd.openxmlformats-officedocument.wordprocessingml.document |
| Author | Wang, Chia-Yih (CDC/DDPHSS/NCHS/DHNES) |
| File Modified | 0000-00-00 |
| File Created | 2022-05-19 |