MCBS Revision to Current Clearance

MCBS Community Additions

MCBS Revision to Current Clearance
Proposed Changes to Community and Facility Interviews and Effect on Burden

Effect on
Annual
Burden

Community Interview Additions

Section

Addition: CBD for Pain Management

CPQ: Summer
Round

Since (TODAY'S MONTH AND YEAR - 3 MONTH), did you use any of the following to
Increase of manage your pain? Please indicate yes or no to each one.
0.25 minutes
CBD (cannabidiol)

IAQ: Summer
Round

In the last 12 months, did [you/you or any member in the household/(SP)/((SP) or any member
in (SP)'s household] receive benefits from the Food Stamp Program or SNAP (the Supplemental
(01) YES
Nutrition Assistance Program) [,also called (STATE SNAP PROGRAM NAME)]?
Increase of
(02) NO
0.22 minutes
(-8) DON'T KNOW
DO NOT INCLUDE THE WOMEN, INFANTS, AND CHILDREN (WIC)
(-9) REFUSED
SUPPLEMENTAL NUTRITION PROGRAM, THE SCHOOL LUNCH PROGRAM, OR
ANY ASSISTANCE FROM FOOD BANKS OR FOOD PANTRIES.

Addition: Supplemental Nutrition
Assistance Program (SNAP)
Participation

Question Text

Response Options

(01) YES
(02) NO
(-8) DON'T KNOW
(-9) REFUSED

We are now going to ask you some questions about [your/(SP's)] ability to control [your/his/her]
bowel movements. Since (LAST HF MONTH YEAR), [have you/has (SP)] had any of the
following problems?
Addition: Prevalance of Bowel
Incontinence

HFQ:
Fall Round

Increase of [IF NEEDED: Was that because [you/(SP)] [were/was] sick?]
0.80 minutes
SELECT 'NO' IF THE RESPONDENT HAD ANY PROBLEMS DUE TO SHORT-TERM
DIARRHEAL ILLNESSES SUCH AS THE FLU OR A VIRUS.

(01) YES
(02) NO
(-8) Don't Know
(-9) Refused

Leaking gas?

We are now going to ask you some questions about [your/(SP's)] ability to control [your/his/her]
bowel movements. Since (LAST HF MONTH YEAR), have [you/(SP)] had any of the
following problems?
[IF NEEDED: Was that because [you/(SP)] [were/was] sick?]
SELECT 'NO' IF THE RESPONDENT HAD ANY PROBLEMS DUE TO SHORT-TERM
DIARRHEAL ILLNESSES SUCH AS THE FLU OR A VIRUS.

(01) YES
(02) NO
(-8) Don't Know
(-9) Refused

Leaking a small amount of stool?

We are now going to ask you some questions about [your/(SP's)] ability to control [your/his/her]
bowel movements. Since (LAST HF MONTH YEAR), have [you/(SP)] had any of the following
problems?
[IF NEEDED: Was that because [you/(SP)] [were/was] sick?]
SELECT 'NO' IF THE RESPONDENT HAD ANY PROBLEMS DUE TO SHORT-TERM
DIARRHEAL ILLNESSES SUCH AS THE FLU OR A VIRUS.

(01) YES
(02) NO
(-8) Don't Know
(-9) Refused

Leaking a moderate amount of stool, requiring a change of underwear?

We are now going to ask you some questions about [your/(SP's)] ability to control [your/his/her]
bowel movements. Since (LAST HF MONTH YEAR), have [you/(SP)] had any of the
following problems?
[IF NEEDED: Was that because [you/(SP)] [were/was] sick?]
SELECT 'NO' IF THE RESPONDENT HAD ANY PROBLEMS DUE TO SHORT-TERM
DIARRHEAL ILLNESSES SUCH AS THE FLU OR A VIRUS.

(01) YES
(02) NO
(-8) Don't Know
(-9) Refused

Leaking a large amount of liquid stool, requiring a complete change of clothes?

[Have you/Has (SP)] talked about [your/his/her] problem with stool leakage with [your/his/her] (01) YES
doctor or other health professional?
(02) NO
(-8) Don't Know
[IF NECESSARY: This is also referred to as bowel or fecal incontinence.]
(-9) Refused

SHOW CARD HF4
Addition: Oral Health-Related Quality of
Life

HFQ:
Fall Round

Increase of
1.90 minutes Since [LAST HF MONTH YEAR], [have you/has (SP)] had painful aching in [your/their]
mouth? Would you say:

SHOW CARD HF4
Since [LAST HF MONTH YEAR], [have you/has(SP)] had difficulty chewing any foods
because of problems, if any, with [your/their] teeth, mouth, dentures, or jaw? Would you say:

(01) Never
(02) Hardly ever
(03) Occasionally
(04) Fairly often
(05) Very often
(-8) DON'T KNOW
(-9) REFUSED

(01) Never
(02) Hardly ever
(03) Occasionally
(04) Fairly often
(05) Very often
(-8) DON'T KNOW
(-9) REFUSED

MCBS Community Additions

Community Interview Additions

Section

Effect on
Annual
Burden

Question Text

SHOW CARD HF4
Since [LAST HF MONTH YEAR], [have you/has (SP)] felt uncomfortable about the
appearance of [your/their] teeth, mouth, dentures, or jaws? Would you say:[IF NEEDED:
“Uncomfortable” can include a wide spectrum of emotions (embarrassment, anxiety, anger,
sadness, etc.).]

SHOW CARD HF4
Since [LAST HF MONTH YEAR], [have you/has (SP)] had difficulty doing [your/their] usual
activities because of problems, if any, with [your/their] teeth, mouth, dentures, or jaws? Would
you say:[IF NEEDED: “Activities” may include going to a job, doing housework such as light
cleaning, shopping, or running errands, preparing meals, etc.]

SHOW CARD HF4
Since [LAST HF MONTH YEAR], [have you/has (SP)] felt that there has been less flavor in
[your/their] food because of problems, if any, with [your/their] teeth, mouth, dentures, or jaws?
Would you say:

Since (TODAY'S DATE - 12 MONTHS, MONTH AND YEAR), did [you/(SP)] receive any
care at a Veteran's Health Administration facility or receive any other health care paid for by the
VA?
Addition: VA Health Care Enrollment
and Utilization

HIQ:
Fall Round

Net increase
of 0.10
[IF NEEDED: Veteran's Health Administration facilities include VA hospitals, VA medical
minutes
centers, VA outpatient clinics, and VA nursing homes.]

Response Options

(01) Never
(02) Hardly ever
(03) Occasionally
(04) Fairly often
(05) Very often
(-8) DON'T KNOW
(-9) REFUSED

(01) Never
(02) Hardly ever
(03) Occasionally
(04) Fairly often
(05) Very often
(-8) DON'T KNOW
(-9) REFUSED
(01) Never
(02) Hardly ever
(03) Occasionally
(04) Fairly often
(05) Very often
(-8) DON'T KNOW
(-9) REFUSED

(01) YES
(02) NO
(-8) Don't Know
(-9) Refused

INCLUDE PRESCRIBED MEDICINES THROUCH THE DEPARTMENT OF VETERANS
AFFAIRS OR VA.

Since (TODAY'S DATE - 12 MONTHS, MONTH AND YEAR), [have you been/has (SP)
been/was (SP)] enrolled in VA health care?

(01) YES
(02) NO
(-8) Don't Know
(-9) Refused

Community COVID-19 Updates

Community Interview Revisions

Section

Revision to Existing Items: COVID-19

CVQ

Effect on
Annual
Burden

Question Text

Decrease of The next questions are about coronavirus or COVID-19 vaccination. Have you had at least one
0.50 minutes dose of a COVID-19 vaccination?

Response Options

(01) YES
(02) NO
(-8) DON'T KNOW
(-9) REFUSED

How many COVID-19 vaccinations have you received in total?

(01) 1 VACCINATION
(02) 2 VACCINATIONS
(03) 3 VACCINATIONS
(04) 4 OR MORE VACCINATIONS
IF NEEDED: This question is asking for the total number of COVID-19 vaccine doses that [you (-8) DON'T KNOW
have/(SP) has] received since the vaccine first became available in December 2020.
(-9) REFUSED
IF NEEDED: Please include booster shots and any additional doses.

In [PREVIOUS YEAR], did you receive at least one dose of the COVID-19 vaccine?

(01) YES
(02) NO
(-8) DON'T KNOW
(-9) REFUSED

[Have you/Has (SP)] ever tested positive for COVID-19 or been told by a doctor or other health
care provider that [you have/(SP) has] or had COVID-19?
[IF NEEDED: Some COVID-19 tests are done by swabbing the nose or mouth to test for
COVID-19 infection at the time of the test. Other tests look for COVID-19 antibodies by
looking at someone’s blood to see if they have ever been infected with COVID-19. COVID-19
tests can be done at home by yourself or by someone else, and some tests are done by a health
professional.]

(01) YES
(02) NO
(-8) DON'T KNOW
(-9) REFUSED

INCLUDE ANTIBODY TESTS, WHICH TEST WHETHER SOMEONE HAS EVER BEEN
INFECTED WITH COVID-19.

In [PREVIOUS YEAR], [were you/was (SP)] tested at least one time to see whether [you
were/(SP) was] infected with COVID-19?
(01) YES
[IF NEEDED: For example, the test can be done by swabbing the nose or mouth. Some tests can
(02) NO
be done by yourself or by someone else at home, and some tests are done by a health
(-8) DON'T KNOW
professional.]
(-9) REFUSED
INCLUDE ANTIBODY TESTS, WHICH TEST WHETHER SOMEONE HAS EVER BEEN
INFECTED WITH COVID-19.

(01) NASAL OR THROAT SWAB OR SALIVA TEST
THAT WAS COLLECTED OR READ BY A HEALTH
CARE PROFESSIONAL
What kind of test(s) did [you/(SP)] take? A nasal or throat swab or saliva test that was collected
(02) AT-HOME TEST THAT WAS READ BY
or read by a health care professional, an at-home test that was read by yourself or a non-health
YOURSELF OR A NON-HEALTH CARE
care professional, or a blood test to look for COVID-19 antibodies?
PROFESSIONAL
(03) BLOOD TEST TO LOOK FOR COVID-19
SELECT ALL THAT APPLY
ANTIBODIES
(-8) DON'T KNOW
(-9) REFUSED

(01) NONE OF THE TIME
(02) SOME OF THE TIME
(03) MOST OF THE TIME
In [PREVIOUS YEAR], how often did [you/(SP)] wear a facemask when out in public? Would
(04) ALL OF THE TIME
you say none of the time, some of the time, most of the time, or all of the time?
(05) NOT APPLICABLE- R DOES NOT GET OUT(-8)
DON'T KNOW
(-9) REFUSED

Community COVID-19 Updates

Community Interview Revisions

Section

Deletion: COVID-19

CVQ

Effect on
Annual
Burden

Question Text

Decrease of [Have you/Has (SP)] ever suspected that [you have/he has/she has] had the coronavirus or
4.00 minutes COVID-19?

Response Options

(01) YES
(02) NO
(-8) DON'T KNOW
(-9) REFUSED

(01) YES
Since [REFERENCE DATE], [have you/has (SP)] suspected that [you have/he has/she has] had (02) NO
the coronavirus or COVID-19?
(-8) DON'T KNOW
(-9) REFUSED

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.

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?
[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].

(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) YES
(02) NO
(-8) DON'T KNOW
(-9) REFUSED

Since [REFERENCE DATE], has a doctor or other health professional told [you/(SP)] that [you
(01) YES
have/he has/she has] or likely 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
(-9) REFUSED
for COVID-19 or based on symptoms [you have/(SP)] has].

[Have you/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?
[IF NEEDED: For example, the test can be done by swabbing [your/his/her] nose or mouth.
Some tests can be done by yourself or by someone else at home, and some tests are done by a
health professional.]

(01) YES
(02) NO
(-8) DON'T KNOW
(-9) REFUSED

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

Since [REFERENCE PERIOD], [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?
[IF NEEDED: For example, the test can be done by swabbing [your/his/her] nose or mouth.
Some tests can be done by yourself or by someone else at home, and some tests are done by a
health professional.]
DO NOT INCLUDE ANTIBODY TESTS, WHICH TEST WHETHER SOMEONE HAS
EVER BEEN INFECTED WITH CORONAVIRUS.

(01) YES
(02) NO
(-8) DON'T KNOW
(-9) REFUSED

Community COVID-19 Updates

Community Interview Revisions

Section

Effect on
Annual
Burden

Question Text

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?
[IF NEEDED: If [you have/(SP) has] 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/his/her] most recent test.]
DO NOT INCLUDE ANTIBODY TESTS, WHICH TEST WHETHER SOMEONE HAS
EVER BEEN INFECTED WITH CORONAVIRUS.

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

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 have/(SP) has] 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/his/her] most recent test.]

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

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

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

(01) YES
(02) NO
(-8) DON'T KNOW
(-9) REFUSED

Was it not available?

(01) YES
(02) NO
(-8) DON'T KNOW
(-9) REFUSED

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

(01) YES
(02) NO
(-8) DON'T KNOW
(-9) REFUSED

Was there some other reason?

(01) YES
(02) NO
(-8) DON'T KNOW
(-9) REFUSED

[You/(SP) previously reported the following COVID-19 vaccines.]
[Have you/Has (SP)] received any [additional] doses of a COVID-19 vaccine?

(01) YES
(02) NO
(-8) DON'T KNOW
(-9) REFUSED

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

PLEASE ENTER COVID-19 VACCINE DOSES IN THE ORDER THEY WERE
RECEIVED, STARTING FROM THE EARLIEST DOSE RECEIVED TO THE MOST
RECENT DOSE RECEIVED.

Which COVID-19 vaccine did (you/(SP)) get?
IF NEEDED: Examples include Pfizer-BioNTech/Comirnaty, Moderna/Spikevax, and Johnson
& Johnson/Janssen, and Novavax.
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)

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

(01) CONTINUOUS ANSWER

Community COVID-19 Updates

Community Interview Revisions

Section

Effect on
Annual
Burden

Question Text

Response Options

(01) FACILITY ONLY- FACILITY NAME (DO NOT
DISPLAY)
(02) PHARMACY/DRUG STORE
(03) DOCTORS OFFICE OR GROUP PRACTICE
(04) MASS VACCINATION SITE
Where did [you/(SP)] go for this dose of the COVID-19 vaccine?
(05) MANAGED CARE PLAN CENTER/HMO
(06) NEIGHBORHOOD/FAMILY HEALTH
A MASS VACCINATION SITE IS A LOCATION THAT WAS SET UP ESPECIALLY TO CENTER/MEDICAL CLINIC
ADMINISTER COVID-19 VACCINES, OFTEN ORGANIZED BY A LOCAL, STATE, OR (07) COMPANY CLINIC/WORKPLACE
FEDERAL AGENCY. MASS VACCINATION SITES MAY BE LOCATED AT A
(08) WALK-IN URGENT CENTER
SHOPPING CENTER, CONVENTION CENTER, SPORTING FACILITY, CHURCH,
(09) HOSPITAL
LIBRARY, HOSPITAL OR OTHER COMMUNITY LOCATION.
(10) VA FACILITY
(11) HEALTH DEPARTMENT OFFICE
(12) AT HOME
(91) OTHER, SPECIFY
(-8) DON’T KNOW
(-9) REFUSED

OTHER (SPECIFY)

[Have you/Has (SP)] had any other COVID-19 vaccine doses?
PLEASE ENTER COVID-19 VACCINE DOSES IN THE ORDER THEY WERE
RECEIVED, STARTING FROM THE EARLIEST DOSE RECEIVED TO THE MOST
RECENT DOSE RECEIVED.

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?

(01) CONTINUOUS ANSWER

(01) YES
(02) NO
(-8) DON'T KNOW
(-9) REFUSED

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

Since April 1, 2021, [have you/has (SP)] worn a facemask when out in public in response to the (01) YES
coronavirus or COVID-19?
(02) NO
(03) NOT APPLICABLE
IF THE RESPONDENT HAS WORN A FACEMASK IN SOME SETTINGS BUT NOT
(-8) DON'T KNOW
OTHERS (FOR EXAMPLE, INSIDE BUT NOT OUTSIDE), SELECT "YES."
(-9) REFUSED

Deletion: VA Health Care Enrollment
and Utilization

HIQ

N/A

[We recorded that [you/(SP)] served in the Armed Forces of the United States.] Since
(REFERENCE DATE), [have you/has (SP) received/did (SP) receive] health care or health
services or prescribed medicines through the Department of Veterans Affairs or V.A.?

(01) YES
(02) NO
(-8) DON'T KNOW
(-9) REFUSED

Facility COVID-19 Updates

Facility Interview Revisions

Section

Effect on
Annual
Burden

Question Text

Response Options

Has (SP) received any COVID-19 vaccines?
Revision to Existing Items: COVID-19

CV

Decrease of [IF NEEDED: Please include booster shots and any additional doses. ]
0.42 minutes
[IF NEEDED: This question is asking for the total number of COVID-19 vaccine doses that
(SP) has received since the vaccine first became available in December 2020. ]

How many COVID-19 vaccines has (SP) received in total?
[IF NEEDED: Please include booster shots and any additional doses.]
[IF NEEDED: This question is asking for the total number of COVID-19 vaccine doses that
(SP) has received since the vaccine first became available in December 2020. ]

(00) NO
(01) YES
(-8) DON'T KNOW
(-9) REFUSED

(01) ONE VACCINE
(02) TWO VACCINES
(03) THREE VACCINES
(04) FOUR OR MORE VACCINES
(-8) DON'T KNOW
(-9) REFUSED

In (PREVIOUS YEAR), has (SP) received at least one dose of the COVID-19 vaccine?
[IF NEEDED: Please include booster shots and any additional doses. ]
[IF NEEDED: This question is asking for the total number of COVID-19 vaccine doses that
(SP) has received since the vaccine first became available in December 2020. ]

Since (PREVIOUS INTERVIEW DATE/ADMISSION DATE) has (SP) been tested to see
whether (he/she) was infected with coronavirus or COVID-19 at the time of the test?
Deletion: COVID-19

CV

Decrease of
[IF NEEDED: For example, the test can be done by swabbing someone’s nose.]
5.24 minutes
DO NOT INCLUDE ANTIBODY TESTS, WHICH TEST WHETHER SOMEONE HAS
EVER BEEN INFECTED WITH CORONAVIRUS.

(00) NO
(01) YES
(-8) DON'T KNOW
(-9) REFUSED

Did the test find that (SP) had Coronavirus or COVID-19?
(01) YES, THE TEST SHOWED R HAD COVID-19
[IF NEEDED: If (SP) had more than one test since (PREVIOUS INTERVIEW
(02) NO, THE TEST SHOWED R DID NOT HAVE
DATE/ADMISSION DATE) to see whether (he/she) was infected with coronavirus or COVID- COVID-19
19, answer yes if any of them were positive.]
(03) NO RESULTS YET
(-8) DON’T KNOW
DO NOT INCLUDE ANTIBODY TESTS, WHICH TEST WHETHER SOMEONE HAS
(-9) REFUSED
EVER BEEN INFECTED WITH CORONAVIRUS .

Since (PREVIOUS INTERVIEW DATE/ADMISSION DATE) has (SP) received medical care (00) NO
(either inside or outside this (facility/home)) for the coronavirus or COVID-19?
(01) YES
(-8) DON'T KNOW
[IF NEEDED: Please include services provided by all health care personnel.]
(-9) REFUSED

Facility COVID-19 Updates

Facility Interview Revisions

Section

Effect on
Annual
Burden

Question Text

What kind of provider did (he/she) receive care from for the coronavirus or COVID-19?
SELECT ALL THAT APPLY.
CODE BASED ON THE RESPONSE FACILITY RESPONDENT GIVES.

OTHER (SPECIFY)

Response Options

(01) EMERGENCY MEDICAL SERVICE PERSONNEL
(02) NURSES
(03) NURSING ASSISTANTS
(04) PHARMACISTS
(05) PHLEBOTOMISTS
(06) PHYSICIANS
(07) TECHNICIANS
(08) THERAPISTS
(91) OTHER
(-8) DON’T KNOW
(-9) REFUSED

(01) CONTINUOUS

[It was previously reported that (SP) received the following COVID-19 vaccines.]
DOSE 1: [MONTH] [YEAR] [MANUFACTURER]
DOSE 2: [MONTH] [YEAR] [MANUFACTURER]
...
DOSE 10: [MONTH] [YEAR] [MANUFACTURER]

(00) NO
(01) YES
(-8) DON’T KNOW
(-9) REFUSED

Has (SP) received any [additional] COVID-19 vaccines?

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

(01) CONTINUOUS

IT WAS PREVIOUSLY REPORTED THAT (SP) RECEIVED THE FOLLOWING COVID19 VACCINES.
DOSE 1: [MONTH] [YEAR] [MANUFACTURER]
DOSE 2: [MONTH] [YEAR] [MANUFACTURER]
...
DOSE 10: [MONTH] [YEAR] [MANUFACTURER]

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

(01) CONTINUOUS

IT WAS PREVIOUSLY REPORTED THAT (SP) RECEIVED THE FOLLOWING COVID19 VACCINES.
DOSE 1: [MONTH] [YEAR] [MANUFACTURER]
DOSE 2: [MONTH] [YEAR] [MANUFACTURER]
...
DOSE 10: [MONTH] [YEAR] [MANUFACTURER]

Which COVID-19 vaccine did (SP) get?

ONLY USE THE ‘OTHER’ CATEGORY TO ADD VACCINE MANUFACTURERS
APPROVED IN AN FI MEMO

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

OTHER (SPECIFY)

(01) CONTINUOUS

[IF NEEDED: Examples include Pfizer-BioNTech/Comirnaty, Moderna/Spikevax, Johnson &
Johnson/Janssen, and Novavax.]

Facility COVID-19 Updates

Facility Interview Revisions

Section

Effect on
Annual
Burden

Question Text

Response Options

Where did (SP) go for their COVID-19 vaccine in (VACDATMM) (VACDATYY)?

(01) (FACILITY)
(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
(-8) DON’T KNOW
(-9) REFUSED

OTHER (SPECIFY)

(01) CONTINUOUS

Has (SP) had any other COVID-19 vaccine doses?
PLEASE ENTER COVID-19 VACCINE DOSES IN THE ORDER THEY WERE
RECEIVED, STARTING FROM THE EARLIEST DOSE RECEIVED TO THE MOST
RECENT DOSE RECEIVED.
DOSE 1: [MONTH] [YEAR] [MANUFACTURER]
DOSE 2: [MONTH] [YEAR] [MANUFACTURER]
DOSE 3: [MONTH] [YEAR] [MANUFACTURER]
...
DOSE 10: [MONTH] [YEAR] [MANUFACTURER]

Deletion: COVID-19

FC

(00) NO
(01) YES
(-8) DON’T KNOW
(-9) REFUSED

I am now going to ask you some information about (FACILITY)'s experiences during the
Decrease of 3 coronavirus pandemic, also known as COVID-19 or SARS-CoV-2. Given the impact the
(01) Continue
minutes
coronavirus pandemic has had on facilities, the next questions aim to capture the experiences
and challenges facilities such as your own have faced due to the pandemic.

The next questions ask about telehealth services this facility is currently providing.
As of today, are any services provided through telehealth by (FACILITY)?
[IF NEEDED: Telehealth visits include visits by telephone or video.]

(00) NO
(01) YES
(-8) DON’T KNOW
(-9) REFUSED

[As of today] are doctor or other health professional visits outside this facility currently
offered through telehealth? Please include outside visits for both primary and specialty care.
VISITS SHOULD INCLUDE BOTH PRIMARY AND SPECIALTY CARE. IF SERVICES ARE OFFERED
THROUGH TELEHEALTH FOR EITHER PRIMARY OR SPECIALTY CARE OUTSIDE THE FACILITY
ANSWER “YES”.

(00) NO
(01) YES
(02) NOT APPLICABLE
(-8) DON’T KNOW
(-9) REFUSED

[IF NEEDED: “Outside” refers to telehealth visits with off-site primary and specialty care
doctors or other health professionals.]

[As of today] are doctor or other health professional visits inside this facility currently offered
through telehealth? Please include inside visits for both primary and specialty care.
VISITS SHOULD INCLUDE BOTH PRIMARY AND SPECIALTY CARE. IF SERVICES ARE OFFERED
THROUGH TELEHEALTH FOR EITHER PRIMARY OR SPECIALTY CARE INSIDE THE FACILITY
ANSWER “YES”.
[IF NEEDED: "Inside” refers to telehealth visits with primary and specialty care doctors or
other health professionals from this facility.]

(00) NO
(01) YES
(02) NOT APPLICABLE
(-8) DON’T KNOW
(-9) REFUSED

Facility COVID-19 Updates

Facility Interview Revisions

Section

Effect on
Annual
Burden

Question Text

Response Options

[As of today] which of the following services, both inside and outside this facility, are currently (00) NO
offered through telehealth?
(01) YES
(02) NOT APPLICABLE
a. Dental visits
(-8) DON’T KNOW
(-9) REFUSED

b. Psychiatrist or other mental health professional visits

(00) NO
(01) YES
(02) NOT APPLICABLE
(-8) DON’T KNOW
(-9) REFUSED

c. Podiatrist visits

(00) NO
(01) YES
(02) NOT APPLICABLE
(-8) DON’T KNOW
(-9) REFUSED

d. Educational or habilitational services

(00) NO
(01) YES
(02) NOT APPLICABLE
(-8) DON’T KNOW
(-9) REFUSED

(00) NO
(01) YES
(02) NOT APPLICABLE
[IF NEEDED: Other types of services inside or outside the facility may include dieticians, nurse
(-8) DON’T KNOW
practitioners, physician’s assistants, registered nurses, or social workers.]
(-9) REFUSED
e. Any other types of services

OTHER (SPECIFY)

(01) [Continuous answer.]

Now I would like to ask you about vaccine policies this facility may have to prevent the
spread of the flu and COVID-19.

(01) CONTINUE

What is (FACILITY)’s policy about the flu shot for health care personnel?
READ RESPONSE OPTIONS ALOUD:
• Flu shot is required
• Flu shot is recommended
• Neither

(01) VACCINE IS REQUIRED
(02) VACCINE IS RECOMMENDED
(03) NEITHER
(-8) DON’T KNOW
(-9) REFUSED

What (is/will be) (FACILITY)’s policy about the COVID-19 vaccine for health care personnel?
READ RESPONSE OPTIONS ALOUD:
• Vaccine (is/will be) required
• Vaccine (is/will be) recommended
• Neither
• Don't know

What is (FACILITY)’s policy about the flu shot for residents?
READ RESPONSE OPTIONS ALOUD:
• Flu shot is required
• Flu shot is recommended
• Neither

(01) VACCINE (IS/WILL BE) REQUIRED
(02) VACCINE (IS/WILL BE) RECOMMENDED
(03) NEITHER
(-8) DON’T KNOW
(-9) REFUSED

(01) VACCINE IS REQUIRED
(02) VACCINE IS RECOMMENDED
(03) NEITHER
(-8) DON’T KNOW
(-9) REFUSED

What (is/will be) (FACILITY)’s policy about the COVID-19 vaccine for residents?
READ RESPONSE OPTIONS ALOUD:
• Vaccine (is/will be) required
• Vaccine (is/will be) recommended
• Neither
• Don't know

The next questions are about mental health services.

(01) VACCINE (IS/WILL BE) REQUIRED
(02) VACCINE (IS/WILL BE) RECOMMENDED
(03) NEITHER
(-8) DON’T KNOW
(-9) REFUSED

(01) CONTINUE

Does this facility offer…
(00) NO
(01) YES
(-8) DON’T KNOW
FOR EACH ITEM INCLUDE SERVICES OFFERED BY THE FACILITY AND/OR COORDINATED BY THE (-9) REFUSED
FACILITY.
a. Individual Therapy Sessions

Facility COVID-19 Updates

Facility Interview Revisions

Section

Effect on
Annual
Burden

Question Text

Response Options

b. Group Therapy Sessions

(00) NO
(01) YES
(-8) DON’T KNOW
(-9) REFUSED

c. Support Groups

(00) NO
(01) YES
(-8) DON’T KNOW
(-9) REFUSED

d. Art Therapy

(00) NO
(01) YES
(-8) DON’T KNOW
(-9) REFUSED

e. Any Other Types of Mental Health Services

(00) NO
(01) YES
(-8) DON’T KNOW
(-9) REFUSED

The next questions are about social and recreational activities.

(01) CONTINUE

Does this facility provide social and recreational activities within the facility?

(00) NO
(01) YES
(-8) DON’T KNOW
(-9) REFUSED

Does this facility provide social and recreational activities outside the facility?
“OUTSIDE THE FACILITY” REFERS TO ACTIVITIES THAT OCCUR OFF THE FACILITY PREMISES.

YOU HAVE COMPLETED THE COVID-19 FACILITY-LEVEL SECTION.
PRESS "1" TO RETURN TO NAVIGATION SCREEN.

(00) NO
(01) YES
(-8) DON’T KNOW
(-9) REFUSED

(01) CONTINUE