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Attachment E: COVID-19 Monthly Outcome Survey – Ipsos Omnibus COVID Questions
ICR 202305-0990-007 · OMB 0990-0475 · Object 131804701.
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| File Type | application/vnd.openxmlformats-officedocument.wordprocessingml.document |
|---|---|
| File Title | Attachment E: COVID-19 Monthly Outcome Survey – Ipsos Omnibus COVID Questions |
| Author | Colin Macfarlane |
| Last Modified By | Writer |
| File Modified | 2021-01-04 |
| File Created | 2026-10-04 |
| Conversion State | complete |
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Attachment E: COVID-19 Monthly Outcome Survey – Ipsos Omnibus COVID Questions Item #: CV1 Question Type: Single punch CV1: Currently, would you say your physical health is… Select one answer only Variable Label: CV1: Physical health Value Value Label 1 Excellent 2 Very good 3 Good 4 Fair 5 Poor -99 Refused Question Type: Grid CV2. Have you experienced any of the following symptoms in the past 2 weeks? Select one answer from each row in the grid // Randomize subitem order // Variable Name Variable Text Variable Label CV2_1_Fever Fever CV2_1: IPSOS Fever CV2_2_Cough Dry Cough CV2_2: IPSOS Dry cough CV2_3_Breath Shortness of Breath CV2_3: IPSOS Shortness of breath CV2_4_Senses Decreased Sense of Smell/Taste CV2_4: IPSOS Decreased sense of smell and taste CV2_5_Flu Other Flu like Symptoms CV2_5: IPSOS Flu symptoms Value Value Label 1 Yes 2 No 3 Don’t know -99 Refusal Question Type: Grid CV3. Has anyone else in your household besides yourself experienced any of the following symptoms in the past two weeks? Select one answer from each row in the grid // Randomize subitem order // Variable Name Variable Text Variable Label CV3_1_Fever Fever CV3_1: IPSOS Fever CV3_2_Cough Dry Cough CV3_2: IPSOS Dry cough CV3_3_Breath Shortness of Breath CV3_3: IPSOS Shortness of breath CV3_4_Senses Decreased Sense of Smell/Taste CV3_4: IPSOS Decreased sense of smell and taste CV3_5_Flu Other Flu like Symptoms CV3_5: IPSOS Flu symptoms Value Value Label 1 Yes 2 No 3 Don’t know -99 Refusal Question Type: Multi punch CV4: Have you, or someone in your immediate family, been diagnosed with the coronavirus/COVID-19? Select all answers that apply Variable Name Variable Text Variable Label CV4_1_Self Yes, I have CV4_1: IPSOS Self COVID diagnosis CV4_2_Family Yes, someone in my family has CV4_2: IPSOS Family COVID diagnosis CV4_3_No No CV4_3: IPSOS No COVID diagnosis Value Value Label 1 Marked 0 Not Marked Question Type: Multi punch CV5: Have you sought any medical help related to your COVID-19 like symptoms or COVID-19 diagnosis? Select all answers that apply // Ask if CV2 = 1 (any symptoms) OR CV4 = 1 (Yes, I have) // Variable Name Variable Text Variable Label CV5_1_Hospital Gone to a hospital or emergency room CV5_1: IPSOS Hospital or emergency room CV5_2_Urgent care Gone to an urgent care facility CV5_2: IPSOS Urgent care facility CV5_3_Doctor Visited a doctor’s office CV5_3: IPSOS Visited doctor’s office CV5_4_Phone Consulted with a healthcare provider over the phone CV5_4: IPSOS Consulted with healthcare provider over the phone CV5_5_Video Consulted with a healthcare provider using a video chat system CV5_5: IPSOS Consulted with healthcare provider using video chat CV5_6_Chat Consulted with a healthcare provider using chat, text, or email CV5_6: IPSOS Consulted with healthcare provider using chat, text, or email CV5_7_None None of the above CV5_7: IPSOS None of the above Value Value Label 1 Marked 0 Not Marked -100 Valid skip Item #: CV6a Question Type: Single punch CV6a: What was your employment status prior to the coronavirus/COVID-19 pandemic? Select one answer only Variable Label: CV6a: IPSOS Employment status prior to COVID pandemic Value Value Label 1 Employed full time (35 hours or more per week) for pay with an organization or company 2 Employed part time (less than 35 hours per week) for pay with an organization or company 3 Self-employed 4 Unemployed, looking for work 5 Unable to work due to a disability 6 On temporary layoff from a job 7 Retired 8 A student 9 Other -99 Refused Item #: CV6b Question Type: Single punch CV6b: Has your employment status changed since the coronavirus/COVID-19 pandemic? Select one answer only // Ask if CV6a = 1|2|3|4|6|8|9 // Variable Label: CV6b: IPSOS Employment status changed since COVID pandemic Value Value Label 1 Yes 2 No -99 Refused -100 Valid skip Item #: CV6c Question Type: Single punch CV6c: What is your current employment status? Select one answer only // Ask if CV6b = 1 (Yes). All others derived from CV6a. // Variable Label: CV6c: IPSOS Current employment status Value Value Label 1 Employed full time (35 hours or more per week) for pay with an organization or company 2 Employed part time (less than 35 hours per week) for pay with an organization or company 3 Self-employed 4 Unemployed, looking for work 5 Unable to work due to a disability 6 On temporary layoff from a job 7 Retired 8 A student 9 Other -99 Refused -100 Valid skip Item #: CV7a Question Type: Single punch CV7a: Are you classified as an essential worker? Select one answer only // Ask if EMPLOYMENT = 1|2|3 // Variable Label: CV7a: IPSOS Essential worker Value Value Label 1 Yes 2 No 3 Don’t know -99 Refused -100 Valid skip Item #: CV7b Question Type: Single punch CV7b: Are you a healthcare worker? Select one answer only // Ask if EMPLOYMENT = 1|2|3 // Variable Label: CV7b: IPSOS Healthcare worker Value Value Label 1 Yes 2 No 3 Don’t know -99 Refused -100 Valid skip Item #: CV8a Question Type: Single punch CV8a: Below is a list of different kinds of health insurance. Which of the following was your primary source of insurance coverage prior to the coronavirus/COVID-19 pandemic? Select one answer only Variable Label: CV8a: IPSOS Insurance coverage prior to COVID pandemic Value Value Label 1 Health insurance through your or someone else’s employer or union 2 Medicare, a government plan that pays healthcare bills for people aged 65 or older and for some disabled people 3 Medicaid, or any state government medical assistance plan for those with lower incomes 4 Health insurance that you bought from the federal Health Insurance Marketplace, also known as Healthcare.gov, or a state-run Health Insurance Marketplace 5 Veteran’s Affairs (VA), Department of Defense, or other military programs 6 Health insurance from some other source 7 I do not have any healthcare insurance/coverage -99 Refused Item #: CV8b Question Type: Single punch CV8b: Has your health insurance status changed since the coronavirus/COVID-19 pandemic? Select one answer only Variable Label: CV8b: IPSOS Insurance changed since COVID pandemic Value Value Label 1 Yes 2 No -99 Refused Item #: CV8c Question Type: Single punch CV8c: What is your current primary source of insurance coverage? Select one answer only // Ask if CV8b = 1. All others derived from CV8a // Variable Label: CV8c: IPSOS Current insurance coverage Value Value Label 1 Health insurance through your or someone else’s employer or union 2 Medicare, a government plan that pays healthcare bills for people aged 65 or older and for some disabled people 3 Medicaid, or any state government medical assistance plan for those with lower incomes 4 Health insurance that you bought from the federal Health Insurance Marketplace, also known as Healthcare.gov, or a state-run Health Insurance Marketplace 5 Veteran’s Affairs (VA), Department of Defense, or other military programs 6 Health insurance from some other source 7 I do not have any healthcare insurance/coverage -99 Refused -100 Valid skip Question Type: Multi punch CV9: Since the coronavirus/COVID-19 pandemic, have you received any of the following financial assistance from the government? Select all answers that apply Variable Name Variable Text Variable Label CV9_1_Unemployment benefits Unemployment benefits CV9_1: IPSOS Unemployment benefits CV9_2_COVID enhanced COVID-19 related enhanced unemployment benefits CV9_2: IPSOS COVID related enhanced unemployment benefits CV9_3_CARES CARES Act check (direct stimulus payments) CV9_3: IPSOS CARES Act check CV9_4_None None of the above CV9_4: IPSOS None Value Value Label 1 Marked 0 Not Marked Question Type: Multi punch CV10: Have you changed your daily routine in any way specifically because of the coronavirus/COVID-19 pandemic? Select all answers that apply // Ask CV10_1 & CV10_2 if XPARENT = 1 // Variable Name Variable Text Variable Label CV10_1_Children home I have kept my children home from school CV10_1: IPSOS kept children home from school CV10_2_Home schooled I home schooled my children CV10_2: IPSOS home schooled children CV10_3_Work from home I have worked from home more than before the pandemic CV10_3: IPSOS worked from home more than before the pandemic CV10_4_Return to work I have recently returned to work after a temporary closure of my company CV10_4: IPSOS returned to work after temporary closure CV10_5_None None of the above CV10_5: IPSOS None Value Value Label 1 Marked 0 Not Marked -100 Valid skip Question Type: Grid CV11. Has anyone else in your household besides yourself experienced any of the following symptoms in the past two weeks? Select one answer from each row in the grid // Randomize subitem order // Variable Name Variable Text Variable Label CV11_1_Nervous Feeling nervous, anxious, or on edge CV11_1: IPSOS Household nervous, anxious, on edge CV11_2_Worrying Not being able to stop or control worrying CV11_2: IPSOS Household not able to stop worrying CV11_3_Depressed Feeling down, depressed or hopeless CV11_3: IPSOS Household feeling down, depressed, or hopeless CV11_4_Little interest Little interest or pleasure in doing things CV11_4: IPSOS Household little interest or pleasure Value Value Label 1 Not at all 2 Several days 3 More than half the days 4 Nearly every day -99 Refusal Question Type: Grid CV12. How difficult have these problems made it for you to do your work, take care of things at home, or get along with other people? Select one answer only // Ask if matching CV11 = 2|3|4. Randomize subitem order // Variable Name Variable Text Variable Label CV12_1_Nervous Feeling nervous, anxious, or on edge CV12_1: IPSOS Self nervous, anxious, on edge CV12_2_Worrying Not being able to stop or control worrying CV12_2: IPSOS Self not able to stop worrying CV12_3_Depressed Feeling down, depressed or hopeless CV12_3: IPSOS Self feeling down, depressed, or hopeless CV12_4_Little interest Little interest or pleasure in doing things CV12_4: IPSOS Self little interest or pleasure Item #: CV13 Question Type: Single punch CV13: During the past week, how much of your day have you been spending at home during your normal working or waking hours, including your front or back yard? Select one answer only Variable Label: CV13: IPSOS Time spent at home Value Value Label 1 The entire day. I never go outside my home 2 Most of the day, with an occasional trip outside my home 3 Some of the day. I am in and out of my home all day 4 Very little of the day. I am rarely at home -99 Refused Item #: CV14 Question Type: Multi punch CV14: During the past week, when you were outside your home, did you practice any of the following? // Ask if CV13 = 2|3|4. Randomize response option order // Variable Label: CV14: IPSOS COVID 14 Value Value Label 1 Kept social distance from others 2 Wore a mask 3 Avoided enclosed spaces 4 Washed or sanitized hands frequently 5 None of the above -99 Refused -100 Valid skip Value Value Label 1 Marked 0 Not Marked -100 Valid skip We would now like to ask you some questions about coronavirus (COVID-19) prevention and social distancing. Item #: CV15 Question Type: Single punch CV15: Approximately how many times yesterday did you wash your hands with soap and water or use hand sanitizer? Select one answer only Variable Label: CV15: IPSOS Wash hands yesterday Value Value Label 1 0 times 2 1-6 times 3 More than 6 times -99 Refused Item #: CV16 Question Type: Single punch CV16: For how long do you usually wash your hands each time? Select one answer only // Ask if CV15 = 2|3. // Variable Label: CV16: IPSOS Wash hands time Value Value Label 1 Less than 10 seconds 2 10-19 seconds 3 20 seconds or more -99 Refused -100 Valid skip