UCSD Covid App

CO-CREATE-Ex Research Survey

Alcohol and Tobacco

How often do you have a drink containing alcohol? Never Monthly or less 2-4 times a month 2-3 times a week 4 or more times a week Don't know or refuse to answer

Do you smoke cigarettes? Every Day Some Days Rarely Not at all Prefer not to answer Don't know

If you smoke every day, on average, how many cigarettes per day do you smoke?

Do you use electronic cigarettes every day, some days, rarely, or not at all? Every Day Some Days Rarely Not at all Prefer not to answer Don't know

Health Status

Do you have any of the following conditions? Select all that apply

Autoimmune disease Yes No Prefer not to answer Immunocompromised condition Yes No Prefer not to answer Hypertension (HTN, high blood pressure) Yes No Prefer not to answer Chronic kidney disease (CKD) Yes No Prefer not to answer Cancer diagnosis and/or treatment within the past 12 months Yes No Prefer not to answer Cardiovascular disease (CVD or heart disease) Yes No Prefer not to answer Diabetes Yes No Prefer not to answer Asthma Yes No Prefer not to answer Chronic obstructive pulmonary disease (COPD) Yes No Prefer not to answer Other chronic lung disease Yes No Prefer not to answer Sickle Cell Anemia Yes No Prefer not to answer Depression Yes No Prefer not to answer Alcohol or substance use disorder Yes No Prefer not to answer Intravenous drug use Yes No Prefer not to answer Other chronic condition Yes No Prefer not to answer Other Mental Health Disorder Yes No Prefer not to answer

How tall are you without shoes? Please choose the units you would like to use for height Feet and inches

Feet Inches

Meters and centimeters

Meters Centimeters

Don't know Prefer not to answer How much do you weigh? Please choose the units you would like to use for weight Kilograms

Pounds

Prefer not to answer Would you say your health is excellent, very good, good, fair, or poor? Excellent Very good Good Fair Poor Prefer not to answer Don't know Have you ever received a flu vaccination? Yes No Don't know Prefer not to answer

Have you received a flu vaccination in the last 12 months? Yes No Don't know No Answer

Disability

Do you have a disability that interferes with your ability to carryout daily activities?
Examples of daily activities include walking,climbing stairs, shopping, balancing a checkbook, bathing or dressing. Yes No Prefer not to answer

Because of a physical, mental, or emotional condition, do you have serious difficulty concentrating, remembering, or making decisions?
(5 years of age or older) Yes No Prefer not to answer Do you have serious difficulty walking or climbing stairs?
(5 years of age or older) Yes No Prefer not to answer Do you have difficulty dressing or bathing?
(5 years of age or older) Yes No Prefer not to answer Because of a physical, mental, or emotional condition, do you have difficulty doing errands alone such as visiting a doctor's office or shopping?
(15 years of age or older) Yes No Prefer not to answer

Are you deaf, or do you have serious difficulty hearing? Yes No Prefer not to answer Are you blind, or do you have serious difficulty seeing, even when wearing glasses? Yes No Prefer not to answer

Demographics

What languages are spoken at home? English Spanish Tagalog Vietnamese Arabic Prefer Not to Answer Other

Specify other languages read, understood, or spoken at home. Albanian Apache Bengali/Bangla Bhutanese Burmese Cantonese Cape Verde Creole Creole Chamoru Chuukese Dakota Fijian French Hawaiian Hmong Ilokano Karen Khmer/Cambodian Kinyarwanda Korean Kosraean Lakota Lingala Mam Mandarin Marshallese Mixteco Nakota Navajo Nepali Portuguese Pohnpeian Russian Sign Language Somali Somoan Swahili Thai Tongan Triqui Zapoteco Other

What is your preferred language at home?

Please specify:

What is the highest level of education you have achieved in any country?
Grades are roughly equivalent to years of school. Have never gone to school 5th grade or less 6th to 8th grade 9th to 12th grade, no diploma High school graduate or GED completed Some college level/Technical/Vocational degree Bachelor's degree Other advanced degree (Master's, Doctoral degree) Prefer not to answer Don't know What is your gender identity? Woman Man Transgender man/Female-to-male (FTM) Transgender woman/Male-to-female (MTF) Gender non-binary/Genderqueer/Gender nonconforming Agender Bigender Two-spirit None of these describe me Prefer not to answer What best describes your sexual orientation? Gay Lesbian Straight; that is, not gay or lesbian, etc. Bisexual None of these decribe me Prefer not to answer

Testing and Vaccination

Why did you get a COVID-19 vaccine?
Check all that apply I want(ed) to keep my family safe I want(ed) to keep my community safe I want(ed) to keep myself safe I have(had) a chronic health problem, like asthma or diabetes My doctor told me to get a COVID-19 vaccine I don't(didn't) want to get really sick from COVID-19 I want(ed) to feel safe around other people I believe(d) life won't go back to normal until most people get a COVID-19 vaccine by my school or workplac for travel Other Not Applicable Prefer not to answer

Why did you NOT get a COVID-19 vaccine?
Check all that apply I am/was allergic to vaccines I don't/didn't like needles I am/was not concerned about getting really sick from COVID-19 I am/was concerned about side effects from the vaccine I don't/didn't think vaccines work very well I don't/didn't trust that the vaccine will be safe I don't/didn't believe the COVID-19 pandemic is as bad as some people say it is I don't/didn't want to pay for it I don't/didn't know enough about how well a COVID-19 vaccine works Other Not Applicable Prefer not to answer

What month and year did you first test positive for COVID-19?

If you were to test positive for COVID-19, would you be able to isolate without losing your job? Yes No Don't know Prefer not to answer If you would be exposed to someone with COVID-19, would you be able to quarantine without losing your job? Yes No Don't know Prefer not to answer I know where I can get COVID-19 testing in my community. Strongly disagree Disagree Neither disagree or agree Agree Strongly agree Prefer not to answer It is easy to get tested for COVID-19. Strongly disagree Disagree Neither disagree or agree Agree Strongly Agree Prefer not to answer

What month and year did you first test positive for COVID-19?

What was the result of your most recent COVID-19 test? Negative Positive Never obtained results Indeterminate Don't know Prefer not to answer How were you tested for your most recent test? Nasal Swab Throat Swab Blood Sample Saliva Prefer not to answer

Long COVID-19 Symptoms

Do you know what Long COVID is? Yes No Don't Know Prefer not to answer

Long COVID is an illness that people may get after COVID-19.Common signs include fatigue, breathing problems, brain fog,stroke, heart attack, and poor control of blood sugar.

Long COVID is sometimes called long-haul COVID, post COVID-19,long-term effects of COVID, or chronic COVID.

Has a doctor diagnosed you with Long COVID? Yes No Don't know Prefer Not to Answer

Housing and Employment

Who lives in your home? Just me Living with roommates Living with spouse, no kids Living with kids, no spouse Family including kids Family with 3 generations (parents, children, grandchildren) Family with 4 generations None of these Prefer not to answer

Are you currently living in transitional housing, staying in a shelter, or experiencing homelessness Yes No Prefer not to answer Don't know

Do you live in any of these A group care setting Nursing home Residential care facilility for people with intellectual and developmental disabilities A psychiatric treatment facility A group home A board or care home Prison or jail A halfway house Foster care Homeless or in no consistent shelter Somewhere else Prefer not to answer

Where do you stay/live?

Have you, or has anyone in your household, experienced a loss of employment income since the start of the COVID-19 pandemic (March 2020)? Yes No Prefer not to answer What best describes your working situation? Working Now Only temporarily laid off, sick leave or maternity leave Looking for work, unemployed Retired Disabled, permanently or temporarily Keeping house Student Prefer not to answer Don't know Other(Specify)

Current employment status, Other-specify

Are you considered an essential worker? An essential worker is someone who was required to go to work even when stay at home orders were in place. Yes No Prefer not to answer Don't know Would any of these describe where you work? If you work multiple jobs, select the closest match to your main job. Nursing care facilities Visiting nurse or home health aide service Building cleaning services Public transportation Corrections facility EMT or paramedic services Meat packing farm facility Agriculture and food production facility Grocery store Construction No Prefer not to answer In your workplace, do you have access to necessary facilities to wash? Yes, all of the time Yes, most of the time Some of the time Rarely Not at all Prefer not to answer Does your work require you to be in close contact (i.e. within 6 ft) with others? Yes, all of the time Yes, most of the time Some of the time Rarely Not at all Prefer not to answer In your workplace, do you have access to necessary personal protective equipment (PPE)? Yes, all of the time Yes, most of the time Some of the time Rarely Not at all Not applicable Prefer not to answer

What is the primary kind of health insurance or health care plan that you have now?
Exclude plans that pay for only one type of service (such as, nursing home care, accidents, family planning, or dental care) and plans that only provide extra cash when hospitalized. I do NOT have health insurance Private (purchased directly or through Employment) Public (Medicare, Medicaid, Tricare) Don't know Prefer not to answer Did you lose health insurance coverage because of the COVID-19 pandemic? Yes No Prefer not to answer Don't know The COVID-19 pandemic may cause challenges for some people,whether they get COVID-19 or not. In the past 6 months have you or your family experienced any of the below challenges? Getting the health care I need (including for mental health) No, not a challenge Yes, a minor challenge Yes, this is a major challenge Prefer not to answer Having a place to stay/live No, not a challenge Yes, a minor challenge Yes, this is a major challenge Prefer not to answer Getting enough food to eat No, not a challenge Yes, a minor challenge Yes, this is a major challenge Prefer not to answer Having clean water to drink No, not a challenge Yes, a minor challenge Yes, this is a major challenge Prefer not to answer Getting the medicine I need No, not a challenge Yes, a minor challenge Yes, this is a major challenge Prefer not to answer Getting to where I need to go No, not a challenge Yes, a minor challenge Yes, this is a major challenge Prefer not to answer