July 06, 2020 
COVID-19 Questionnaire 
English  v2.4 

Table of contents
Section 1 | Identification
Section 2 | COVID-19 related health questions
Section 3 | Mental Health Assessment
Section 4 | Maternal and Child Health
Section 5 | Behaviour and Knowledge
Section 6 | Economic Questions
Section 7 | Social Impact
Section 8 | Environmental Impact

[ENTER INTRODUCTORY TEXT FROM LOCAL SITE HERE]

Section 1 | Identification

1.1 
Ask to speak to the person who participated in your population study 

[Site-Specific Introduction script]

a. Participant attends call     [ Q 1.4]
b. Participant not available   [ Ask to schedule a time to call back]
c. Participant has died

1.2 
What date did he/she die? 

[PROMPT FOR DATE]

__________

1.3 
Did a health professional think that the death was caused by COVID-19?

Yes  	[ Stop]
No   	[ Stop]

1.4 
What is your gender? 
Female 
Male [ Note: Skips Section 4]
Other (specify) __________

Section 2 | COVID-19 related health questions

2.1 
Do you think that you have, or have had, COVID-19? 

Yes, confirmed by a positive test 				
Yes, suspected by a healthcare professional but not tested 	
Yes, my own suspicions 					 
No 	[Q2.3]        

2.2 
When were you told / when did you think you had COVID-19? 

[PROMPT FOR DATE]

___________________

2.3 
The following are questions about certain symptoms that you might have experienced, since the beginning of this year (1st January, 2020).  First,  I want you to think back to the period this year before [enter lockdown date/criterion here].

In the period between January 1st, 2020 and [enter lockdown date/criterion here], did you have any of the following symptoms? 

[READ OPTIONS AND SELECT ONE OR MORE]

Abdominal pain/tummy ache
Cough that was new and persistent
Chills (feeling too cold)
Diarrhoea
Fever (feeling too hot) 
Loss of sense of smell
Loss of sense of taste
Nausea and/or vomiting
Shortness of breath affecting normal activities
Sore throat
Tightness in the chest or chest pain
Tiredness that was more than normal
None of the above

2.4
Now I want you to think about the period since [enter lockdown date here]. In the period since [enter lockdown date here] have you had any of the following? 

[READ OPTIONS AND SELECT ONE OR MORE]

Abdominal pain/tummy ache
Cough that was new and persistent
Chills (feeling too cold)
Diarrhoea
Fever (feeling too hot) 
Loss of sense of smell
Loss of sense of taste
Nausea and/or vomiting
Shortness of breath affecting normal activities?
Sore throat
Tightness in the chest or chest pain
Tiredness that was more than normal
None of the above

[IF YES TO ANY ITEM IN Q2.3 or Q2.4 Q2.5, otherwise Q2.9]

2.5 
What date did your symptoms first appear? 

[ENTER DATE: MUST BE AFTER OCTOBER 01, 2019]

DD/MM/YYYY

2.6 
Do you still have symptoms? 

Yes 	[ 2.6.1]
No 	[ 2.6.2]

2.6a 
For how many days have you had these symptoms? 

[ENTER NUMBER OF DAYS]

___ Days [validation: requires number]

2.6b 
How long in days did the symptoms last? 

[ENTER NUMBER OF DAYS]

___ Days [validation: requires number]

2.7 
Did you seek medical attention for the symptoms? 

Yes  
No	[ Q 2.9]

2.8 
Where did you go, or who did you call, to get assessment and treatment for the symptoms? 

[READ OPTIONS AND SELECT ONE OR MORE]

Phoned doctor or healthcare provider
Visited a community health worker
Visited a government hospital/clinic
Visited a private hospital/clinic
Visited an NGO hospital/clinic
Visited a traditional healer or herbalist
Visited a drug shop / pharmacy
Other (specify)__________ 
None of the above

2.9
Have you been in close contact** with anyone with known or suspected COVID-19 in the last 2 weeks? 

** “Close contact” means being within 2 metres of somebody for 15 minutes or more.

Yes, I was in contact with a confirmed/tested COVID-19 case
Yes, I was in contact with a suspected COVID-19 case
No, not to my knowledge

2.10 
I am now going to ask you about other health conditions. Has a doctor or other healthcare provider told you that you have one of the following conditions? 

[READ OPTIONS AND SELECT ONE OR MORE]

Alcohol or other substance misuse
Anaemia 
Asthma
Brain or nerve condition (e.g. dementia, Parkinson’s)
Cancer 
Diabetes (Type I or II)
Heart disease or heart problems
Hepatitis B or C, or other chronic liver disease
HIV
Hypertension (high blood pressure)
Mental health problems (e.g. depression, anxiety, or other mental disorders)
Stroke
TB 
Other lung condition COPD, bronchitis or emphysema
Other condition causing a weakened immune system/reduced ability to deal with infections (as a result of a disease or treatment) 
None of the above

2.11
Do you currently take any medication prescribed by a healthcare professional for a long-term condition?
 
Yes  
No	[ Q2.14]

2.12 
Have you run out of any of these medications in the last 2 weeks? 

Yes  
No	[ Q2.14]

2.13 
What was the main reason for running out? 

[OPEN SINGLE RESPONSE. MATCH TO ANSWER. PROMPT IF NEEDED]  

Afraid of go out to get medication because of fear of COVID-19 infection
Lockdown restricted me from going out
Unable to go out for other reasons
Drug shop/pharmacy out of stock
Government medicine out of stock
Unable to afford the medication
Other reason (specify)__________

2.14 
Have you tried to see a healthcare provider (e.g. doctor, nurse, community health worker) in the last 2 weeks?

Yes   
No   [ Q3.1]

2.15 
What was the main reason for wanting to see a healthcare provider? 

[OPEN SINGLE RESPONSE. MATCH TO ANSWER. PROMPT IF NEEDED]  

Advice or evaluation for possible COVID-19
Pregnancy 
Treatment of a new condition
Treatment of a pre-existing condition (e.g. blood pressure, cancer, HIV)
Vaccination or well child care
Other reason (specify)__________

2.16 
Were you successful in seeing a healthcare provider?

Yes   
No, tried but could not be seen	[ Q2.18]

2.17
Was that by phone consultation or in person?

By phone consultation	[ Q3.1]
In person   		[ Q3.1]
                                                                
2.18 
What was the main reason for not being able to see a healthcare provider? 

[OPEN SINGLE RESPONSE. MATCH TO ANSWER. PROMPT IF NEEDED]  

Afraid to go out due to fear of COVID-19 infection
Lockdown restricted me from going out
Unable to go out for other reason
Unable to afford
Clinic closed
Other reason (specify) __________

Section 3 | Mental Health Assessment

3.1
Over the last 2 weeks, how often have you been bothered by the following problems?	
	Not at all	Several days	More than half the days	Nearly every day	
Feeling nervous, anxious or on edge					
Not being able to stop or control worrying					

3.2
Over the last 2 weeks, how often have you been bothered by the following problems?	
	Not at all	Several days	More than half the days	Nearly every day	
Little interest or pleasure in doing things					
Feeling down, depressed or hopeless					

Section 4 | Maternal and Child Health 

[SECTION IS SKIPPED IF RESPONDENT IS MALE] 

4.1 
Are you pregnant? 
Yes		[ Q4.2]
No		[ Q4.6]
4.2
Is this your first child? 
Yes	
No
4.3 
How many weeks pregnant are you? 
[ENTER A NUMBER]
_____________

4.4. How many antenatal clinic visits have you attended? 
[ENTER A NUMBER]
_____________

4.5 
Have you had any vaccinations in pregnancy since [enter lockdown/criterion date here]? 
Yes		[ Q5.1 (End of section: if currently pregnant, questions to not apply)]
No		[ Q5.1 (End of section: if currently pregnant, questions to not apply)]

4.6 
Have you had a baby this year? 
Yes		[ Q4.7]
No		[ Q5.1 (End of section)]

4.7 
How long ago did you give birth? 
[ENTER DAYS, WEEKS, OR MONTHS. PROMPT FOR SPECIFIC DATE]
__________

4.8 
Where did you give birth? 
Home
Hospital
Health centre
Other (specify)__________
4.9 
Are you breastfeeding your infant? 
Yes	
No, using formula milk 
No, using other food sources	
No, other reason (specify)__________ [If the baby has died Q5.1 (end section)]

4.10 
Have you taken your baby for their vaccines? 
Yes		[ Q5.1 (End of section)]
No		
4.11 
What are the reasons for not taking your baby for vaccines?
Clinic is closed – no staff
Clinic closed – no vaccines
Family advised not to go – fear of a COVID-19 vaccine
Fear of COVID-19
Unable to get to clinic – no money
Unable to get to clinic – no transport
Other reasons

Section 5 | Behaviour and Knowledge

5.1 
Since [enter lockdown/criterion date here], did you change your behaviour by doing any of the following? 

[SELECT ONE OR MORE]

Avoided crowded areas
Avoided going for walks or exercise outside
Avoided going to church
Avoided going to markets
Avoided going to restaurants/bars/pubs
Avoided going to sports venues (added from elsewhere)
Avoided going to the doctor/health centre/clinic
Avoided public transport/taxis
Avoided taking my children out of my home
Avoided travelling long distances
Cancelled my usual social activities 
Did not attend lectures (if a student)
Did not go to a grocery store or pharmacy
Did not go to work / or worked from home
Did not go shopping for non-essential things 
Did not leave the house
Followed coughing and sneezing recommendations 
Followed handwashing recommendations
Tried to avoid physical contact with people
Used hand sanitizer
Used tissues more than usual 
Wore a face mask outside my home
Wore gloves while going out of my home
None of the above

5.2  
Since [enter lockdown/criterion date here], has your family been able to access enough soap and water to wash your hands regularly?

Yes   
No   
5.3
Do you have any school-going children in your household?

Yes   
No   [ Q6.1 (End of section)]

5.4
How did they primarily access education since [enter lockdown/criterion date here]? 

[SELECT ONE]
	
They could attend school most of the time
Someone in the household provided education
The school had a program over the internet
They accessed radio or TV programmes
They did not receive any education

Section 6 | Economic Questions

6.1 
Before [enter lockdown/criterion date here], how well would you say your household was managing financially? 

[READ OPTIONS AND SELECT ONE]

Living comfortably
Doing all right
Just about getting by 
Finding it quite difficult
Finding it very difficult

6.2 
Overall, how do you feel your household’s current financial situation compares to before [enter lockdown/criterion date here]? 

[READ OPTIONS AND SELECT ONE]

Much worse off
A little worse off
About the same
A little better off
Much better off

6.3 
Before [enter lockdown/criterion date here], which of the following statements best describes the food eaten in your household?  

[READ OPTIONS AND SELECT ONE]

You all always had enough of the kinds of foods you wanted to eat.
You all had enough to eat, but not always the kinds of food you wanted.
You (or a household member) sometimes did not have enough to eat.
You (or a household member) often didn't have enough to eat.

6.4 
Which of the following statements best describes the food eaten in your household in the last week? 

[READ OPTIONS AND SELECT ONE]

You all always had enough of the kinds of foods you wanted to eat.
You all had enough to eat, but not always the kinds of food you wanted.
You (or a household member) sometimes did not have enough to eat.
You (or a household member) often didn't have enough to eat.

6.5
Do you work in a place other that your home? [SELECT ONE]

Yes
No	[ Q6.7]
6.6 
Does your work require you to be in close contact (i.e. within 2 metres) with others, who you do not live with, including while travelling to work? 

[READ OPTIONS AND SELECT ONE]
 
Yes, all of the time
Yes, most of the time
Some of the time
Rarely
Not at all

6.7 
Who is the main earner in your household? 

[SELECT ONE]

Me			[ Q6.8a]
My child 		[ Q6.8b]
My partner		[ Q6.8b]
My parent		[ Q6.8b]
My sibling		[ Q6.8b]
Other relative		[ Q6.8b]
Other non-relative	[ Q6.8b]

6.8a. 
What is your main occupation? 

[MATCH RESPONSE TO ONE OF THE OPTIONS BELOW]

Agriculture, forestry and fishing 							[ Q6.9a]
Mining and quarrying 								[ Q6.9a]
Manufacturing 									[ Q6.9a]
Electricity, gas, steam and air conditioning supply 				[ Q6.9a]
Water supply; sewerage, waste management and remediation activities 		[ Q6.9a]
Construction 									[ Q6.9a]
Wholesale and retail trade; repair of motor vehicles and motorcycles 		[ Q6.9a]
Transportation and storage 							[ Q6.9a]
Accommodation and food service activities 					[ Q6.9a]
Information and communication 							[ Q6.9a]
Financial and insurance activities 						[ Q6.9a]
Real estate activities 								[ Q6.9a]
Professional, scientific and technical activities 					[ Q6.9a]
Administrative and support service activities 					[ Q6.9a]
Public administration and defence; compulsory social security 			[ Q6.9a]
Education 									[ Q6.9a]
Human health and social work activities 						[ Q6.9a]
Arts, entertainment and recreation 						[ Q6.9a]
Other service activities 								[ Q6.9a]
Activities of households as employers; undifferentiated goods- and services-producing activities of households for own use 						[ Q6.9a]
Activities of extraterritorial organizations and bodies 				[ Q6.9a]
No income									[ Q6.9a]

6.8b. 
Which of the following is the occupation of the main earner of your household? 

[MATCH RESPONSE TO ONE OF THE OPTIONS BELOW]

Agriculture, forestry and fishing 							[ Q6.9b]
Mining and quarrying 								[ Q6.9b]
Manufacturing 									[ Q6.9b]
Electricity, gas, steam and air conditioning supply 				[ Q6.9b]
Water supply; sewerage, waste management and remediation activities 		[ Q6.9b
Construction 									[ Q6.9b]
Wholesale and retail trade; repair of motor vehicles and motorcycles 		[ Q6.9b]
Transportation and storage 							[ Q6.9b]
Accommodation and food service activities 					[ Q6.9b]
Information and communication 							[ Q6.9b]
Financial and insurance activities 						[ Q6.9b]
Real estate activities 								[ Q6.9b]
Professional, scientific and technical activities 					[ Q6.9b]
Administrative and support service activities 					[ Q6.9b]
Public administration and defence; compulsory social security 			[ Q6.9b]
Education 									[ Q6.9b]
Human health and social work activities 						[ Q6.9b]
Arts, entertainment and recreation 						[ Q6.9b]
Other service activities 								[ Q6.9b]
Activities of households as employers; undifferentiated goods- and services-producing activities of households for own use 						[ Q6.9b]
Activities of extraterritorial organizations and bodies 				[ Q6.9b]
No income									[ Q6.9b]

6.9a. 
Which of the following describes your income since before [enter lockdown/criterion date here]? 

[READ OPTIONS AND SELECT ONE]

Income stopped 		[ Q6.10]
Income reduced 		[ Q6.10]
Income unchanged 		[ Q6.10]
Income increased 		[ Q6.10]
Don't know 			[ Q6.10]

6.9b. 
Which of the following describes the income of the main earner since before [enter lockdown/criterion date here]? 

[READ OPTIONS AND SELECT ONE]

Income stopped
Income reduced
Income unchanged
Income increased
Don't know

6.10 
Which of the following describes your household’s income in the last 12 months? 

[READ OPTIONS AND SELECT ONE]

Income stopped	
Income reduced	
Income unchanged
Income increased
Don’t know

6.11 
Have there been times in the last 2 weeks when you or your household have been unable to afford any of these? 

[READ OPTIONS, SELECT ONE OR MORE]

Accommodation/rent
Communications (mobile/internet)
Electricity 
Food
Loan repayments 
Medicine
School fees
Transport
Water
Medical care 
None of the above

6.12 
Have there been times in the last 2 weeks when you or your household have been unable to access any of these? 

[READ OPTIONS, SELECT ONE OR MORE]

Community-based food support
Education
Electrical supply
Food shopping
Health services
Transport services
Water supply
Medical care
Other (specify)_________
None of the above

Section 7 | Social Impact

7.1
Has your living arrangement changed because of the COVID-19 pandemic?

Yes
No 		[ Q7.3]

7.2 How has it changed? 

[MATCH TO ONE OR MORE]

I moved to my current address temporarily because of the COVID-19 pandemic 
Another person (e.g. sibling, adult, child, parent) has moved into my address because of the COVID-19 pandemic  
Another person I lived with has moved elsewhere because of the COVID-19 pandemic  

7.3
Since [enter lockdown/criterion date here], have you seen any changes in the following situations, in your community? 

[FOR EACH ITEM, GIVE THE FOLLOWING OPTIONS: 
INCREASED, STAYED SAME, DECREASED, DON’T KNOW]

Violence against women 
Violence against men
Violence against children 
Child neglect
Marital problems (separation/divorce)

Section 8 | Environmental Impact

8.1
How many rooms are in your accommodation (not including the kitchen and bathroom)? 

[ENTER A NUMBER]

	__________

8.2
Including yourself, how many people live in your accommodation? 

[ENTER A NUMBER FOR EACH CATEGORY]

___ Adults aged 60 years old or older.

___ Adults aged 18-59 years.

___ Children aged less than 18 years.
       
8.3
What type of outside space do you have where you can exercise or play? 

[READ OPTIONS AND SELECT ONE OR MORE]

Private to your household only
Shared with two or more households living close by 
Public space (open to anyone)
No space to exercise or play