1 Pe Covid-19

Form Approved

OMB#

Exp. Date

Proposed COVID-19 questions for the Medical Expenditure Panel Survey (MEPS)

First time asked (All rounds spring 2023 or new household member in fall rounds)

1. {Have you/Has {PERSON}} ever had COVID-19?

IF NECESSARY, SAY: Include being told by a doctor that you had or likely had COVID-19. Also include antibodies or blood tests as well as other forms of testing for COVID-19, such as a nasal swabbing or throat swabbing. Also include if you had close contact with someone who had COVID-19 and you had symptoms.

Response options: Yes, No, Don’t know, Refused

2. Did {you/{PERSON}} have any symptoms lasting 3 months or longer that {you/{PERSON}} did not have prior to having COVID-19?

IF NECESSARY, SAY: Long term symptoms may include tiredness or fatigue, difficulty thinking, concentrating, forgetfulness or memory problems, sometimes referred to as "brain fog," difficulty breathing or shortness of breath, joint or muscle pain, fast-beating or pounding heart (also known as heart palpitations), chest pain, dizziness on standing, menstrual changes, changes to taste/smell, and inability to exercise.

Response options: Yes, No, Don’t know, Refused

Routing logic: Asked of all people who said yes to question 1.

3. {Do you/Does {PERSON}} have symptoms now?

Response options: Yes, No, Don’t know, Refused

Routing logic: Asked of all people who said yes to question 2.

4. How much do these long-term symptoms reduce {your/{PERSON}’s} ability to carry out day-to-day activities compared with the time before {you/he/she} had COVID-19? Would you say not at all, a little, a lot, or somewhere in between a little and a lot?

Response options: Not at all, A little, A lot, Somewhere in between a little and a lot, Don’t know, Refused

Routing logic: Asked of all people who said yes to question 3.

5. Please think about the last 12 months, that is between {MONTH YEAR-1} and today. Did {you/{PERSON}} last have COVID-19 within the past 12 months or more than 12 months ago?

Response options: Within the past 12 months, More than 12 months ago, Don’t know, Refused

Routing logic: Asked of all people who said yes to question 1.

6. What month and year did {you/{PERSON}} last have COVID-19?

Response options: (Text entry), Don’t know, Refused

Routing logic: Asked of all people who said “Within the past 12 months” to question 5.

This survey is authorized under 42 U.S.C. 299a. The confidentiality of your responses to this survey is protected by Sections 944(c) and 308(d) of the Public Health Service Act [42 U.S.C. 299c-3(c) and 42 U.S.C. 242m(d)]. Information that could identify you will not be disclosed unless you have consented to that disclosure. Public reporting burden for this collection of information is estimated to average 7 minutes per response, the estimated time required to complete the survey. An agency may not conduct or sponsor, and a person is not required to respond to, a collection of information unless it displays a currently valid OMB control number. Send comments regarding this burden estimate or any other aspect of this collection of information, including suggestions for reducing this burden, to: AHRQ Reports Clearance Officer Attention: PRA, Paperwork Reduction Project (0935-0118) AHRQ, 5600 Fishers Lane, Room #07W42, Rockville, MD 20857.