MVP COVID-19 Survey 2.0_62 w Cover Sheet_edited_11022020

Million Veteran Program (MVP)

COVID-19 Survey

OMB No. 2900-______
Estimated Burden: 25 minutes

Expiration Date: __________

The Paperwork Reduction Act of 1995: This information is collected in accordance with section 3507 of the Paperwork Reduction Act of 1995. Accordingly, we may not conduct or sponsor, and you are not required to respond to, a collection of information unless it displays a valid OMB number. We anticipate that the time expended by all individuals who complete this survey will average 25 minutes. This includes the time it will take to follow instructions, gather the necessary facts, and respond to questions asked. Customer satisfaction is used to gauge customer perceptions of VA services, as well as customer expectations and desires. This survey data will be analyzed in conjunction with biospecimens collected as part of the MVP and will assist with identification of potential biomarkers and allow researchers to analyze the incidence and outcomes of COVID-19 using genomic data. Participation in this survey is voluntary, and failure to respond will have no impact on benefits to which you may be entitled.

Privacy Act Statement: Information on this form is collected in accordance with Information on this form is collected in accordance with the Privacy Act of 1974 (5 U.S.C. § 552a), Code of Federal Regulations Title 38, Part 16, and the MVP research protocol approved by the VA Central Institutional Review Board.

Information gathered will be kept private to the extent provided by law. The data we collect will be aggregated, and disclosure of information will involve the release of statistical data and other non-identifying data for improving the quality of service delivery. No information will be attributable to you as an individual.

Section A: Demographics

1. What is today’s date? 7. What is your current marital status?

/ /

mm dd

yyyy

• Married

• Civil commitment

• Cohabitating

• Divorced

• Widowed

• Never married

2. What is your date of birth?

/ /

mm dd yyyy

3. What is your gender?

 Separated

8. Including yourself, how many people currently live in your household?

1	2	3	4	5	6	7	8	9+
								

• Male

• Female

• Prefer not to answer

8. Which income category represents the total income of your household from all sources (before taxes and deductions)

4. Are you Spanish, Hispanic, or Latino?

   • ^{No, not Spanish, Hispanic, Latino}

   • ^{Yes, Mexican, Mexican American,} Chicano

   • ^{Yes, Puerto Rican}

   • ^{Yes, Cuban}

   • ^{Yes, other Spanish, Hispanic, Latino}

5. What is your race? (Mark all that apply)

during the last 12 months?

 Less than $10,000

 $10,000 - $19,999

 $20,000 - $29,999

 $30,000 - $39,999

 $40,000 - $49,999

 $50,000 - $59,999

 $60,000 - $74,999

 $75,000 - $99,999

 White

 ^{Black / African -} American

 American Indian

/ Alaska Native

 Chinese

 Japanese

 Asian Indian

 Other Asian

 Filipino

 Pacific Islander

 Other

 $100,000 - $149,999

 $150,000 or more

 Prefer not to answer

10. What is your height:

feet inches

4. What is your highest degree or level of school you have completed?

   • ^{Less than high school}

   • ^{High school diploma / GED}

   • ^{Some college credit, but no degree}

   • Associate’s degree (e.g., AA, AS)

   • ^{Bachelor’s degree (e.g., BA, BS)}

   • 

     • ^{Professional or Doctorate degree}

     
     

     ^{Master’s degree (e.g., MA, MS, MBA)}

11. What is your weight:

pounds

11. In which branch of the service did you serve? (Mark all that apply)

17. How often do you have six or more drinks on one occasion?

• Army

• Navy

• Air Force

• Coast Guard

• Marine Corps

• National Guard

• Merchant Marines

• NOAA

• Public Health Service

• None (Skip to Qu. 15)

  • Never

  • Less than monthly

  • Monthly

  • 2 – 3 times per week

  • 4 or more times per week

17. In your lifetime have you smoked a total

13. Please indicate whether your service

was:

of at least 100 cigarettes, cigars, or pipes?

• Active Duty

• Yes

(Skip to Qu. 21)

• Reserves Only

• Not Applicable (Not in the military)

13. When did you serve? (Mark all that apply)

    • September 2001 or later

    • August 1990 to August 2001 (includes Gulf War)

    • May 1975 to July 1990

    • August 1964 to April 1975 (Vietnam era)

    • February 1955 to July 1964

    • July 1950 to January 1955 (Korean War)

    • January 1947 to June 1950

    • December 1941 to December 1946 (WWII)

    • November 1941 or earlier

14. How often do you have a drink containing alcohol

Have you ever smoked daily or almost every day for at least one year?

• Yes _{ No}

19. Do you smoke now?

    • Yes, daily

    • Yes, occasionally

    • Not at all

The following questions concern electronic vaping products for nicotine use. Do not include marijuana use.

19. Have you ever used an e-cigarette or other electronic vaping product, even just one time, in your entire life?

    • Yes

    • No (Skip to Qu. 23)

    • Prefer not to answer (Skip to Qu. 23)

• Never (Skip to Qu. 18)

• 1 – 3 days per month

• 1 day per week

• 2 – 3 days per week

• 4 – 5 days per week

• 6 or more days per week

 Don’t know (Skip to Qu. 23)

19. Do you NOW use e-cigarettes or other electronic vaping products every day, some days, or not at all?

    • Every day

16. How many drinks containing alcohol do you have on a typical day when you are drinking?

• Some days

• Not at all

• Prefer not to answer

• 1 or 2

• 3 or 4

• 5 or 6

• 7 to 9

• 10 or more

• Don’t know

Section B: COVID-19 Exposure/Household Contact

23. Have you been in close contact with anyone with COVID-19 like symptoms?

    • Yes, I was in contact with a person with COVID-19 who was confirmed positive by a test

    • Yes, I was in contact with a person with COVID-19 symptoms, but was not confirmed by a test

24. Has anyone in your household had COVID-19? Please do not include yourself.

• ^No

23. Are you a healthcare worker helping to manage patients with COVID-19?

• No, not to my knowledge

• Yes

• No

• Don’t know

• ^{Prefer not to answer}

Section C: COVID-19 Symptoms/Diagnosis

23. Have you experienced any of the following symptoms more than normal since January 2020? Please check "Yes" or "No" next to each symptom and provide the date the symptoms began.

If yes, please indicate the date and number of days you experienced any of these symptoms.	No	Yes	Date Symptoms Began [MM/DD/YYYY]	Number of Days You Experienced Symptom
a. Coughing a lot for more than an hour, or 3 or more coughing episodes in 24 hours
b. Shortness of breath
c. Unusual chest pain or tightness in your chest
d. Fatigue (struggling to get out of bed)
e. Feeling of heaviness in arms or legs
f. Headache
g. Loss of sense of smell or taste
h. Sore throat
i. Diarrhea, nausea and/or vomiting
j. Fever/chills (temp>100.4 Fahrenheit)

MVP COVID-19 Survey v3_62_11-02-2020 Page 3

23. Did you seek medical attention for these symptoms? If yes, please include the date that you received medical care.

1. If yes, please indicate where you received care and the date care was received:

• VA facility (Date) [MM/DD/YYYY]

• Non-VA facility (Date) [MM/DD/YYYY]

2. If yes, how long after your symptoms started did you seek care?

• Less than 2 days

• 2 – 7 days

• Greater than 1 week

• No (Skip to Qu. 41)

23. Did doctors use a laboratory test to check that you didn’t have influenza (Flu)?

    • ^Yes

    • ^No

    • ^{Don’t know}

23. Have you been diagnosed with COVID-19?^{­­­­­­­­­­ Please indicate if you were diagnosed at a VA-facility or Non-VA facility.}

    • Yes, confirmed by a positive laboratory test ______VA-Facility _____Non-VA Facility

    • Yes, suspected by a doctor but not confirmed by a test (Skip to Qu. 41)

    • ^{No (Skip to Qu. 41)}

23. Please indicate the type of laboratory test you received to diagnose COVID-19 and date of test.

• Yes, by nasal swab (PCR) Date _____ [MM/DD/YYYY]

• Yes, by blood test (antibody)

Date _____[MM/DD/YYYY]

• Yes, by self-administered at-home testing Date

• Yes, by another test

Date _____[MM/DD/YYYY]

• ^{Don’t know the type of test}

Date _____[MM/DD/YYYY]

23. Is there a suspected source of your COVID-19?

    • Travel related

    • ^Spouse

    • ^Child

    • ^{Extended family member}

    • ^{Coworker or other work contact}

• ^{Friend or other social contact}

• ^{Don’t know}

• ^{Prefer not to answer}

Section D: COVID-19 Medical Treatment and Hospitalization

23. Did you receive medical treatment for COVID-19?

    • Yes ^{­­­­­­­­­­­}­­­­­­­­

____ VA Facility ____Non-VA Facility

• No

23. Were you hospitalized for COVID-19?

    • Yes ^{­­­­­­­­­­­}­­­­­­­­

____ VA Facility ____Non-VA Facility

• No (Skip to Qu. 38)

23. When were you admitted to the hospital for treatment of COVID-19?

/ /

mm dd yyyy

23. What date were you discharged from the hospital after treatment of COVID-19?

/ /

mm dd yyyy

23. Did you require a breathing tube through the mouth for respiratory support while in the hospital (intubation / mechanical ventilation / respirator)?

    • ^Yes

    • ^No

23. Were you hospitalized in an Intensive Care Unit (ICU) for treatment of COVID-19?

    • ^Yes

    • ^No

38. Do you know if doctors used any of the following medications to treat your illness while you were sick with COVID-19? (Mark all that apply)

Medication	Did doctors use this medication?	If yes, indicate date
Tamiflu (oseltamivir) or Xofluza (baloxavir marboxil)	Yes No	MM/DD/YYYY
Chloroquine or Hydroxychloroquine	Yes No	MM/DD/YYYY
Azithromycin	Yes No	MM/DD/YYYY
Remdesivir	Yes No	MM/DD/YYYY
Dexamethasone	Yes No	MM/DD/YYYY
Convalescent Plasma	Yes No	MM/DD/YYYY
Experimental medications/treatments	Yes No	MM/DD/YYYY
Other treatment	Yes No	MM/DD/YYYY
Don’t know	Yes No	MM/DD/YYYY

38. Did you receive respiratory support at home to treat your COVID-19, such as oxygen therapy by nasal prong or facemask or CPAP machine?

    • Yes

    • No (Skip to Qu. 41)

38. If yes, for how long did you need respiratory support at home? Please enter the duration of your respiratory support in days

Section E: COVID-19 Impact Behavior/Well-Being

The next questions ask about your behaviors and well-being since the COVID-19 pandemic and the impact it has had on you. For each of the statements below, please select the best choice that describes your response. (Select only one response for each question or statement).

38. Which of the following have you done since the COVID-19 pandemic?

	Never	Sometimes	Most of the Time	Always
Used a face mask or other face covering while in public
Used gloves while in public
Washed your hands with soap or used hand sanitizer several times a day
Cleaned high touch surfaces like door handles, counters, faucets, and remote controls
Practiced social distancing (avoiding contact with anyone outside of the home)
Avoided contact with people who could be high-risk
Avoided eating at restaurants
Avoided public spaces, gatherings, or crowds
Avoided gatherings of more than 50

38. Since the COVID-19 pandemic started, have any of the following aspects of your life changed?

		Decreased	Stayed the Same	Increased	Not Applicable
a.	Amount you sleep
b.	Amount of physical activity you do
c.	Amount you smoke/vape
d.	Amount of alcohol you drink
e.	Number of hours you work in usual workplace
f.	Number of hours you work at home
g.	Time spent talking to family/friends
h.	Time spent talking to work colleagues
i.	Practicing relaxation / mindfulness / meditation
j.	Time watching TV/streaming services
k.	Time spent reading or listening to the news
l.	Time spent on social media
m.	Time spent playing video games
n.	Time spent doing hobbies/things you enjoy
o.	Amount you eat
p.	Amount of money you’ve spent

38. Over the past 2 weeks, have you been bothered by any of these problems?

		Not at all	Several days	More days than not	Nearly every day
a.	Feeling nervous, anxious, or on edge
b.	Not being able to stop or control worrying
c.	Feeling down, depressed, or hopeless
d.	Little interest or pleasure in doing things

38. Since the COVID-19 pandemic, for each of the statements below please

select the best choice that describes how you feel. Select only one response for each question or statement.

		Never	Rarely	Sometimes	Usually	Always	Don’t know or N/A
Social Isolation
a.	I feel left out…
b.	I feel that people barely know me…
c.	I feel isolated from others…
d.	I feel that people are around me, but not with me…

38. Since the COVID-19 pandemic, for each of the statements below please

select the best choice that describes how you feel. Select only one response for each question or statement.

		Never	Rarely	Sometimes	Usually	Always	Don’t know or N/A
Emotional Support
a.	I have someone who will listen to me when I need to talk.
b.	I have someone to confide in or talk to about myself or my problems.
c.	I have someone who makes me feel appreciated.
d.	I have someone to talk with when I have a bad day.

38. Since the COVID-19 pandemic, for each of the items below please select the

best choice describing the degree of impact. Select only one response for each question or statement.

		No Loss	Minimal Loss	Noticeable Loss	Extreme Loss	Don’t Know or N/A
a.	Adequate food
b.	Your residence / home you live in
c.	Things you need for your children or members of your household
d.	Money for extras
e.	Savings or emergency money
f.	Adequate income
g.	Financial credit
h.	Your retirement security
i.	Free time
j.	Time for enough sleep
k.	Feeling valuable to other people
l.	A feeling of intimacy with one or more family members
m.	The feeling that you’re accomplishing the goals in your life
n.	Time with your loved ones
o.	The sense of a daily routine
p.	Health of a family member / friend
q.	Stable employment
r.	Ability to organize tasks
s.	Time needed to do your work
t.	Understanding from your boss
u.	Support from your co-workers
v.	The chance to get more training or education

	Continued	No Loss	Minimal Loss	Noticeable Loss	Extreme Loss	Don’t Know or N/A
w.	Feeling of being independent
x.	Companionship with others
y.	Feeling that your life has meaning or purpose
z.	Involvement with your church
aa.	Help with tasks at home
bb.	Loyalty of friends
cc.	Help with childcare
dd.	Involvement in organizations or clubs

Section F: Medical Conditions/Comorbidity

38. 

    48.

    We'd like to ask about your general health. Please tell us if you have ever been diagnosed with the following conditions. Check the appropriate box and indicate the year of diagnosis and whether you currently take any medication(s) (“TAKE MEDS”) for that condition. (Mark all that apply)

Circulatory System Problems Mental Health Disorders

High blood pressure (Hypertension)

Stroke

Transient ischemic attack (TIA)

Heart attack Coronary artery /

Coronary heart disease (includes angina) Peripheral vascular disease

High cholesterol

Pulmonary embolism or deep vein thrombosis (DVT)

Congestive heart failure

Other circulatory system problem

YEAR

YES DIAGNOSED MEDS

Anxiety reaction / Panic disorder

Attention deficit hyper- activity disorder (ADHD)

Bipolar disorder

Post traumatic stress disorder (PTSD)

Depression

Eating disorder Personality disorder

Schizophrenia

Social phobia

Other mental health disorder

YEAR

YES DIAGNOSED MEDS

^{Skeletal / Muscular Problems} Hearing / Vision

Osteoarthritis Rheumatoid arthritis Other arthritis

Gout Osteoporosis

Other skeletal / muscular

problem

YEAR

YES DIAGNOSED MEDS

Cataracts Glaucoma

Macular degeneration

Blindness, all causes

Tinnitus or ringing in the ears

Severe hearing loss or partial deafness in one or both ears

YEAR

YES DIAGNOSED MEDS

Infectious Diseases

Cancer

Tuberculosis Hepatitis C HIV / AIDS

Other infectious disease

YEAR TAKE YES DIAGNOSED MEDS

Breast cancer

Colon cancer / Rectal cancer

Lung cancer Prostate cancer

YEAR TAKE YES DIAGNOSED MEDS

Kidney Disease Skin cancer

Kidney disease without dialysis

Kidney disease with

YEAR TAKE YES DIAGNOSED MEDS

Other cancer

Nervous System Problems

YEAR

TAKE

dialysis

Acute kidney disease with no current dialysis

Digestive System Problems

YEAR

TAKE

Migraine headaches

Other headaches Memory loss or

YES DIAGNOSED MEDS

Bowel obstruction

Acid reflux / GERD Peptic ulcers

Irritable bowel syndrome (IBS)

Colon polyps

Ulcerative colitis

Crohn’s disease

Celiac disease / Sprue

Other digestive system disorder

YES DIAGNOSED MEDS

impairment

Dementia (includes Alzheimer’s, vascular, etc.)

Concussion or loss of consciousness

Traumatic brain injury

Spinal cord injury or impairment

Epilepsy / Seizure

Parkinson^’s disease

Amyotrophic lateral sclerosis (Lou Gehrig’s disease)

Multiple sclerosis

Other nervous system problem

Skin condition (e.g., Eczema, Psoriasis)

38. Did you receive the following vaccines while in the military? If yes, please write in

39. In general, would you say your health is:

the year of the last vaccine dose.

Anthrax

• Excellent

• ^{Very Good}

• Good

• Fair

• Poor

• ^{Don’t Know}

Small Pox

38. In the PAST YEAR, have you received health care that was paid for by any of the following insurance types? (Mark all that apply)

Yes

• ^No

Year Vaccinated:

• Private insurance

• TRICARE

• Medicare

• Veterans Choice Program

• VA health care

• ^{Don’t Know}

• Medicaid

• Indian Health

Rabies

Yes

• ^No

Year Vaccinated:

38. In the PAST YEAR, about how much of your health care did you get at a VA facility (e.g., doctor’s visits, hospitalizations, urgent care visits, or

• 

  
  

  ^{Don’t Know}

Yellow Fever

counseling)?

• None

 1 – 25%

 51 – 75%

 76 – 99%

Yes

• ^No

Year Vaccinated:

 26 – 50%

 100%

• ^{Don’t Know}

Typhoid

38. In the PAST YEAR, how many times were you a patient in a hospital overnight or longer?

Yes

• ^No

Year Vaccinated:

VA Facility

• None

 1 - 3

 4 - 6

 7 - 9

• 10 or more

• ^{Don’t Know}

Non-VA Healthcare Facility

Japanese Encephalitis

• None

 4 - 6

• 10 or more

Yes

• ^No

 1 - 3

 7 - 9

38. How many prescription medications do you currently receive from:

VA Pharmacy

38. How many non-prescription medications do you currently receive from:

VA Pharmacy

• None

 1 - 3

 4 - 6

 7 - 9

• 10 or more

• None

 1 - 3

 4 - 6

 7 - 9

• 10 or more

Non-VA Pharmacy ^{Non-VA Pharmacy}

• None

 1 - 3

 4 - 6

 7 - 9

• 10 or more

• None

 1 - 3

 4 - 6

 7 - 9

• 10 or more

38. Did you receive the seasonal flu shot in the last six months?

• Yes

____ VA Facility ____Non-VA Facility

• No

• Don’t know

38. In the past, how likely were you to receive your annual flu shot?

• Always

• Most of the time

• Some of the time

• Never

Comments concerning the accuracy of the survey burden estimate and suggestions for reducing this burden should be sent to: MVP at AskMVP@va.gov

MVP COVID-19 Survey v3_62_11-02-2020 Page 2