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Topic <br />Recommended/Sample Questions <br />COVID- 19 <br />How would you rate your household on the following: [Excellent/Good/Fair/Poor/Don't know] <br />Impacts (physical, <br />emotional, <br />economic) <br />Overall physical health <br />Overall emotional/social health <br />Overall economic health <br />We know the COVID-19 pandemic is challenging in many ways. Please rate how much of a <br />problem, if at all, the following are for your household CURRENTLY. [Major problem, Moderate <br />problem, Minor problem, Not a problem, Don't know] <br />Household member(s) have COVID- 19 or COVID-like symptoms (fever, shortness of breath, dry cough) <br />Access to medical services (e.g., emergency care, basic medical care and needed prescriptions) <br />A shortage of food <br />A shortage of sanitation and cleaning supplies (e.g., toilet paper, disinfectants, etc. <br />Loss of employment income <br />Loss of income from retirement savings <br />Trouble paying for food or housing <br />Not being able to exercise <br />Feeling alone/isolated, not being able to socialize with other people <br />Feeling nervous, anxious or on edge <br />Boredom <br />Not knowing when pandemic will end/not feeling in control <br />Household members not getting along <br />Lack of technology to perform online work (e.g., internet access, computer, tablet, etc.) <br />Lack of technology to perform online schooling (e.g., internet access, computer, tablet, etc.) <br />Helping my children with on-line schooling <br />Not knowing if schooling will be on-line (virtual) <br />Lack of skills to use technology to communicate <br />Providing financial, emotional, or other support for extended family not living with you <br />Lack of childcare/supervision <br />Not knowing enough about COVID- 19 testing locations, costs, or eligibility to be tested <br />Long wait times at COVID- 19 testing facilities <br />Long wait times to get COVID- 19 tests back <br />Not knowing how safe it is for my household to participate in reopening activities <br />COVID prevalence <br />Because COVI D-19 test kits have not always been easily accessible, it is difficult to estimate our <br />and testing <br />community's exposure. People who have had COVID-like symptoms may not have been tested <br />and it can be hard to distinguish symptoms from the flu or common cold. <br />Have you and/or other household members been tested for COVID-19 (viral test for people who <br />actively have an infection)? [Never tested, Not tested but presumed positive by medical professional, <br />Tested and waiting results, Tested negative, Tested positive] <br />Me <br />Someone else in my household <br />Have you and/or other household members been tested for COVID-19 antibodies (antibody test <br />for people who have had COVID but are not actively infected)? [Never tested, Not tested but <br />presumed positive by medical professional, Tested and waiting results, Tested negative, Tested positive] <br />Me <br />Someone else in my household <br />