May we contact you again over the next 12 months, and possibly longer, to see how you're doing and ask you these questions again?
* must provide value
Yes
No
Please indicate an email address that we may contact you at in the future to provide a follow-up survey request. (This is confidential and will not be sold, shared, or accessible by anyone other than the researchers listed on the cover sheet).
* must provide value
1 1. Do you have at least one child under the age of 18 that has been diagnosed with a food allergy by a doctor?
* must provide value
Yes
No
Are you a member of a food allergy support group?
* must provide value
Yes
No
In which country do you live?
* must provide value
In which state do you live? (If located in the USA)
* must provide value
Are you at least 18 years of age or older?
* must provide value
Yes
No
What is your current age in years?
* must provide value
What is your gender?
* must provide value
Female
Male
What is your race/ethnicity? Mark all that apply.
* must provide value
Other:
* must provide value
What is your current marital status?
* must provide value
Married
Divorced
Single
What is the highest level of education you have completed?
* must provide value
Less than high school
High school
2 year college
4 year college
Graduate degree
Which of the following categories best represents the combined income for all family members in your household for the past 12 months before taxes?
* must provide value
Less than $25,000
$25,000 - $49,999
$50,000 - $99,999
$100,000 - $199,999
$200,000 - $299,999
$300,000 or more
How many children do you have under 18 years of age?
* must provide value
1
2
3
4
5 or more
Do you currently live in the same household as your food-allergic child(ren)?
* must provide value
Yes
No
Please describe how often you see your food-allergic child(ren):
* must provide value
Child #1: How old is your child? (please indicate if your answer is in years or months)
* must provide value
Child #1: What is his/her gender?
* must provide value
Female
Male
What is his/her race/ethnicity? Mark all that apply.
* must provide value
Child #1: Please indicate other race/ethnicity answer(s):
* must provide value
Child #1: Does he/she have any of the following? Mark all that apply.
* must provide value
Child #1: Has he/she ever been diagnosed with food allergy?
* must provide value
Yes
No
Child #1: Has he/she ever experienced anaphylaxis?
* must provide value
Yes
No
Child #1: Has he/she out grown any food allergies?
* must provide value
Yes
No
Child #1: Please list all food allergies that your child has outgrown:
* must provide value
Child #1: Does your child have a current physician-diagnosed food allergy?
* must provide value
Yes
No
Child #1: To which foods is he/she CURRENTLY allergic?
* must provide value
Food #1
* must provide value
Do you have another child under the age of 18 that has a food allergy?
* must provide value
Yes
No
Child #2: How old is your child? (please indicate if your answer is in years or months)
* must provide value
Child #2: What is his/her gender?
* must provide value
Female
Male
What is his/her race/ethnicity? Mark all that apply.
* must provide value
Child #2: Please indicate other race/ethnicity answer(s):
* must provide value
Child #2: Does he/she have any of the following? Mark all that apply.
* must provide value
Child #2: Has he/she ever been diagnosed with food allergy?
* must provide value
Yes
No
Child #2: Has he/she ever experienced anaphylaxis?
* must provide value
Yes
No
Child #2: Has he/she out grown any food allergies?
* must provide value
Yes
No
Child #2: Please list all food allergies that your child has outgrown:
* must provide value
Child #2: Does your child have a current physician-diagnosed food allergy?
* must provide value
Yes
No
Child #2: To which foods is he/she CURRENTLY allergic?
* must provide value
Food #1
* must provide value
Do you have another child under the age of 18 that has a food allergy?
* must provide value
Yes
No
Child #3: How old is your child? (please indicate if your answer is in years or months)
* must provide value
Child #3: What is his/her gender?
* must provide value
Female
Male
What is his/her race/ethnicity? Mark all that apply.
* must provide value
Child #3: Please indicate other race/ethnicity answer(s):
* must provide value
Child #3: Does he/she have any of the following? Mark all that apply.
* must provide value
Child #3: Has he/she ever been diagnosed with food allergy?
* must provide value
Yes
No
Child #3: Has he/she ever experienced anaphylaxis?
* must provide value
Yes
No
Child #3: Has he/she out grown any food allergies?
* must provide value
Yes
No
Child #3: Please list all food allergies that your child has outgrown
* must provide value
Child #3: Does your child have a current physician-diagnosed food allergy?
* must provide value
Yes
No
Child #3: To which foods is he/she CURRENTLY allergic?
* must provide value
Food #1
* must provide value
Do you have another child under the age of 18 that has a food allergy?
* must provide value
Yes
No
Child #4: How old is your child? (please indicate if your answer is in years or months)
* must provide value
Child #4: What is his/her gender?
* must provide value
Female
Male
What is his/her race/ethnicity? Mark all that apply.
* must provide value
Child #4: Please indicate other race/ethnicity answer(s):
* must provide value
Child #4: Does he/she have any of the following? Mark all that apply.
* must provide value
Child #4: Has he/she ever been diagnosed with food allergy?
* must provide value
Yes
No
Child #4: Has he/she ever experienced anaphylaxis?
* must provide value
Yes
No
Child #4: Has he/she out grown any food allergies?
* must provide value
Yes
No
Child #4: Please list all food allergies that your child has outgrown
* must provide value
Child #4: Does your child have a current physician-diagnosed food allergy?
* must provide value
Yes
No
Child #4: To which foods is he/she CURRENTLY allergic?
* must provide value
Food #1
* must provide value
Please list any other children with food allergy here. You may include as much information as you would like pertaining to the food allergy, diagnosis, foods outgrown, reaction history, etc.
* must provide value
Have you or your significant other made career changes because of your child's food allergy? Mark all that apply.
* must provide value
Have you or your significant other chosen not to work outside the home because of your child's food allergy? Mark all that apply.
* must provide value
Which of the following resources have you used for food allergy education or support? Mark all that apply.
* must provide value
Other resources:
* must provide value
Since March 1, 2020, have you or someone in your home experience any symptoms of the novel coronavirus (COVID-19)?
* must provide value
No
Yes, someone in my home (not including you)
Yes, multiple people in my home (not including you)
Yes, I experienced such symptoms
Yes, both I and someone in my home experienced such symptoms
I'm not sure/I don't know
Other symptom (specify):
* must provide value
What date did your first symptom start?
* must provide value
Today M-D-Y
In the two weeks prior to developing symptoms, had you traveled outside your state/country?
* must provide value
No
Yes, outside of my state
Yes, outside of my country
In the two weeks prior to developing symptoms, did you have contact with a known COVID-19 case?
* must provide value
No
Yes, someone inside my home
Yes, someone outside my home
In the two weeks prior to developing symptoms, did you have contact with someone who had symptoms of COVID-19, buy who had not yet tested positive or had not yet had a test?
* must provide value
No
Yes, someone in my home
Yes, someone outside my home
Did you consult a healthcare provider or try to get a coronavirus test because of your symptoms?
* must provide value
Yes
No
At what point did you seek care?
* must provide value
Immediately when symptoms began
When you developed a fever
When you had trouble breathing
Some other time
Have you ever been tested for coronavirus?
* must provide value
Yes No
How easy was it for you to get a test for coronavirus?
* must provide value
Very easy Easy Difficult Very difficult
How many times have you been tested for coronavirus?
* must provide value
When were you first tested for coronavirus?
* must provide value
Today M-D-Y
When were you last tested for coronavirus?
* must provide value
Today M-D-Y
Have you ever tested positive for coronavirus?
* must provide value
No, I tested negative
Yes, I tested positive
My results are pending
When did you first test positive for coronavirus?
* must provide value
Today M-D-Y
Other (Specify):
* must provide value
Since March 1, 2020, have you been hospitalized for COVID-19 or because you had difficulty breathing or a respiratory infection?
* must provide value
Yes
No
What is your status now?
* must provide value
You are recovered and symptom free
You are feeling better but not fully recovered (ie, I have symptoms that remain)
You are not feeling better
Why have you not been tested for coronavirus?
* must provide value
You haven't felt sick
You have felt sick, but didn't feel sick enough to get tested
You were told by a healthcare provider to self-quarantine instead of getting tested
You were told or believed testing was not available
You haven't had transportation to or from a testing location
You were worried about not being able to pay
You didn't know where to go for testing
You didn't have someone to watch your children/other people in your care while you went.
You haven't been able to take time off of work for testing
Other
Other reason:
* must provide value
Since March 1, 2020 has anyone in your household experienced any of the following symptoms?
* must provide value
Yes
No
Which household member or child # described on the food allergy worksheet ____?
* must provide value
Other symptom (specify):
* must provide value
What date did this household member's first symptom start?
* must provide value
Today M-D-Y
In the two weeks prior to developing symptoms, had this household member traveled outside your state/country?
* must provide value
No
Yes, outside of my state
Yes, outside of my country
In the two weeks prior to developing symptoms, did this household member have contact with a known COVID-19 case?
* must provide value
No
Yes, someone inside my home
Yes, someone outside my home
In the two weeks prior to developing symptoms, did this household member have contact with someone who had symptoms of COVID-19, but who had not yet tested positive or had not yet had a test?
* must provide value
No
Yes, someone in my home
Yes, someone outside my home
Did this household member consult a healthcare provider or try to get a coronavirus test because of their symptoms?
* must provide value
Yes
No
At what point did this household member seek care?
* must provide value
Immediately when symptoms began
When they developed a fever
When they had trouble breathing
Some other time
Has this household member ever been tested for coronavirus?
* must provide value
Yes No
How easy was it for this household member to get a test for coronavirus?
* must provide value
Very easy Easy Difficult Very difficult
How many times has this household member been tested for coronavirus?
* must provide value
When was this household member first tested for coronavirus?
* must provide value
Today M-D-Y
When was this household member last tested for coronavirus?
* must provide value
Today M-D-Y
Has this household member ever tested positive for coronavirus?
* must provide value
No, they tested negative
Yes, they tested positive
Their results are pending
When did this household member first test positive for coronavirus?
* must provide value
Today M-D-Y
Other (Specify):
* must provide value
Since March 1, 2020, has this household member been hospitalized for COVID-19 or because he/she had difficulty breathing or a respiratory infection?
* must provide value
Yes
No
What is this household member's status now?
* must provide value
They are recovered and symptom free
They are feeling better but not fully recovered (ie, they have symptoms that remain)
They are not feeling better
Why has this household member not been tested for coronavirus?
* must provide value
They haven't felt sick
They have felt sick, but didn't feel sick enough to get tested
They were told by a healthcare provider to self-quarantine instead of getting tested
They were told or believed testing was not available
They haven't had transportation to or from a testing location
They were worried about not being able to pay
They didn't know where to go for testing
They didn't have someone to watch their children/other people in their care while they went.
They haven't been able to take time off of work for testing
Other
Other reason:
* must provide value
Since March 1, 2020 have any other members of your household experienced any of the above symptoms?
* must provide value
Yes
No
Which household member or child # described on the food allergy worksheet ____?
* must provide value
Other symptom (specify):
* must provide value
What date did this household member's first symptom start?
* must provide value
Today M-D-Y
In the two weeks prior to developing symptoms, had this household member traveled outside your state/country?
* must provide value
No
Yes, outside of my state
Yes, outside of my country
In the two weeks prior to developing symptoms, did this household member have contact with a known COVID-19 case?
* must provide value
No
Yes, someone inside my home
Yes, someone outside my home
In the two weeks prior to developing symptoms, did this household member have contact with someone who had symptoms of COVID-19, but who had not yet tested positive or had not yet had a test?
* must provide value
No
Yes, someone in my home
Yes, someone outside my home
Did this household member consult a healthcare provider or try to get a coronavirus test because of their symptoms?
* must provide value
Yes
No
At what point did this household member seek care?
* must provide value
Immediately when symptoms began
When they developed a fever
When they had trouble breathing
Some other time
Has this household member ever been tested for coronavirus?
* must provide value
Yes No
How easy was it for this household member to get a test for coronavirus?
* must provide value
Very easy Easy Difficult Very difficult
How many times has this household member been tested for coronavirus?
* must provide value
When was this household member first tested for coronavirus?
* must provide value
Today M-D-Y
When was this household member last tested for coronavirus?
* must provide value
Today M-D-Y
Has this household member ever tested positive for coronavirus?
* must provide value
No, they tested negative
Yes, they tested positive
Their results are pending
When did this household member first test positive for coronavirus?
* must provide value
Today M-D-Y
Other (Specify):
* must provide value
Since March 1, 2020, has this household member been hospitalized for COVID-19 or because he/she had difficulty breathing or a respiratory infection?
* must provide value
Yes
No
What is this household member's status now?
* must provide value
They are recovered and symptom free
They are feeling better but not fully recovered (ie, they have symptoms that remain)
They are not feeling better
Why has this household member not been tested for coronavirus?
* must provide value
They haven't felt sick
They have felt sick, but didn't feel sick enough to get tested
They were told by a healthcare provider to self-quarantine instead of getting tested
They were told or believed testing was not available
They haven't had transportation to or from a testing location
They were worried about not being able to pay
They didn't know where to go for testing
They didn't have someone to watch their children/other people in their care while they went.
They haven't been able to take time off of work for testing
Other
Other reason:
* must provide value
Since March 1, 2020 have any other members of your household experienced any of the above symptoms?
* must provide value
Yes
No
Which household member or child # described on the food allergy worksheet ____?
* must provide value
Other symptom (specify):
* must provide value
What date did this household member's first symptom start?
* must provide value
Today M-D-Y
In the two weeks prior to developing symptoms, had this household member traveled outside your state/country?
* must provide value
No
Yes, outside of my state
Yes, outside of my country
In the two weeks prior to developing symptoms, did this household member have contact with a known COVID-19 case?
* must provide value
No
Yes, someone inside my home
Yes, someone outside my home
In the two weeks prior to developing symptoms, did this household member have contact with someone who had symptoms of COVID-19, but who had not yet tested positive or had not yet had a test?
* must provide value
No
Yes, someone in my home
Yes, someone outside my home
Did this household member consult a healthcare provider or try to get a coronavirus test because of their symptoms?
* must provide value
Yes
No
At what point did this household member seek care?
* must provide value
Immediately when symptoms began
When they developed a fever
When they had trouble breathing
Some other time
Has this household member ever been tested for coronavirus?
* must provide value
Yes No
How easy was it for this household member to get a test for coronavirus?
* must provide value
Very easy Easy Difficult Very difficult
How many times has this household member been tested for coronavirus?
* must provide value
When was this household member first tested for coronavirus?
* must provide value
Today M-D-Y
When was this household member last tested for coronavirus?
* must provide value
Today M-D-Y
Has this household member ever tested positive for coronavirus?
* must provide value
No, they tested negative
Yes, they tested positive
Their results are pending
When did this household member first test positive for coronavirus?
* must provide value
Today M-D-Y
Other (Specify):
* must provide value
Since March 1, 2020, has this household member been hospitalized for COVID-19 or because he/she had difficulty breathing or a respiratory infection?
* must provide value
Yes
No
What is this household member's status now?
* must provide value
They are recovered and symptom free
They are feeling better but not fully recovered (ie, they have symptoms that remain)
They are not feeling better
Why has this household member not been tested for coronavirus?
* must provide value
They haven't felt sick
They have felt sick, but didn't feel sick enough to get tested
They were told by a healthcare provider to self-quarantine instead of getting tested
They were told or believed testing was not available
They haven't had transportation to or from a testing location
They were worried about not being able to pay
They didn't know where to go for testing
They didn't have someone to watch their children/other people in their care while they went.
They haven't been able to take time off of work for testing
Other
Other reason:
* must provide value
Since March 1, 2020 have any other members of your household experienced any of the above symptoms?
* must provide value
Yes
No
Which household member or child # described on the food allergy worksheet ____?
* must provide value
Other symptom (specify):
* must provide value
What date did this household member's first symptom start?
* must provide value
Today M-D-Y
In the two weeks prior to developing symptoms, had this household member traveled outside your state/country?
* must provide value
No
Yes, outside of my state
Yes, outside of my country
In the two weeks prior to developing symptoms, did this household member have contact with a known COVID-19 case?
* must provide value
No
Yes, someone inside my home
Yes, someone outside my home
In the two weeks prior to developing symptoms, did this household member have contact with someone who had symptoms of COVID-19, but who had not yet tested positive or had not yet had a test?
* must provide value
No
Yes, someone in my home
Yes, someone outside my home
Did this household member consult a healthcare provider or try to get a coronavirus test because of their symptoms?
* must provide value
Yes
No
At what point did this household member seek care?
* must provide value
Immediately when symptoms began
When they developed a fever
When they had trouble breathing
Some other time
Has this household member ever been tested for coronavirus?
* must provide value
Yes No
How easy was it for this household member to get a test for coronavirus?
* must provide value
Very easy Easy Difficult Very difficult
How many times has this household member been tested for coronavirus?
* must provide value
When was this household member first tested for coronavirus?
* must provide value
Today M-D-Y
When was this household member last tested for coronavirus?
* must provide value
Today M-D-Y
Has this household member ever tested positive for coronavirus?
* must provide value
No, they tested negative
Yes, they tested positive
Their results are pending
When did this household member first test positive for coronavirus?
* must provide value
Today M-D-Y
Other (Specify):
* must provide value
Since March 1, 2020, has this household member been hospitalized for COVID-19 or because he/she had difficulty breathing or a respiratory infection?
* must provide value
Yes
No
What is this household member's status now?
* must provide value
They are recovered and symptom free
They are feeling better but not fully recovered (ie, they have symptoms that remain)
They are not feeling better
Why has this household member not been tested for coronavirus?
* must provide value
They haven't felt sick
They have felt sick, but didn't feel sick enough to get tested
They were told by a healthcare provider to self-quarantine instead of getting tested
They were told or believed testing was not available
They haven't had transportation to or from a testing location
They were worried about not being able to pay
They didn't know where to go for testing
They didn't have someone to watch their children/other people in their care while they went.
They haven't been able to take time off of work for testing
Other
Other reason:
* must provide value
Please list any other household member's and their associated testing experience, symptoms, and/or treatment if you would like.
* must provide value
Have you been able to make arrangements to get you or your household members medications refills?
* must provide value
No
You have been able to arrange for some refills but not all
You are waiting to hear from your physician on how to refill medications
Yes, by home delivery
Yes, picking up at pharmacy
Yes, someone will be picking up medications for you
Since the COVID-19 pandemic (March 1, 2020), have you needed to postpone any medical procedures?
* must provide value
Yes
No
Since the COVID-19 pandemic (March 1, 2020), has anyone in your household missed any scheduled appointments with any health care providers?
* must provide value
Yes
No
Don't know
Refuse to answer
What is the MAIN reason you missed appointments with any healthcare providers in the past month?
* must provide value
Your clinic cancelled your appointment because of COVID-19
Your clinic is closed because of the COVID-19
You had symptoms of COVID-19, so you stayed home
You cancelled the appointment to avoid being around others
You cancelled the appointment because you did not want to be in a healthcare setting
You felt okay or good enough
You did not have money or insurance
You did not want to take public transportation and had no way to get there
You forgot to go/just missed your appointment
You felt disrespected by the medical staff
Don't know
Refuse to answer
Other
Other (specify):
* must provide value
Since March 1, 2020 have you or anyone in your household missed taking medications?
* must provide value
Yes
No
Don't know
Refuse to answer
Since March 1, 2020 what is the MAIN reason you missed taking medications?
* must provide value
You couldn't get your medications because your pharmacy was closed
You couldn't get to the pharmacy because of COVID-19 shutdowns
You couldn't get to the pharmacy because you wanted to avoid being around others
You felt good/didn't need your medications
Your doctor advised you to delay treatment
You were worried about side effects
You didn't have money or insurance to get medicine
You didn't want to take public transportation to get your prescription and had no other way to get there
You forgot to take your medications
Don't know
Refuse to answer
Other
Other (specify):
* must provide value
Have your daily routines changed since March 1, 2020? By daily routines we mean things like your work, school, social, and religious activities, or other ways you spend time.
* must provide value
No, you had no changes to your routines
Yes, you have had mild changes to a few of your routines
Yes, you have had moderate changes to several of your routines
Yes, you have had severe changes across most or all of your routines
Has your household income changed since March 1, 2020?
* must provide value
No, there have been no changes to your household income
Yes, there have been small changes but you are able to meet all your household needs and pay bills
Yes, there have been moderate changes and you have made cuts, but you are able to meet basic needs and pay bills
Yes, there have been severe changes and you are not able to meet basic needs or pay bills
Has your access to food changed since March 1, 2020?
* must provide value
No, your access to food has not changed
Yes, you have had enough food, but difficulty getting to the store or finding items
Yes, you have occasionally been without enough food or good quality food items
Yes, you have frequently been without enough food
Has your access to allergen-free foods changed since March 1, 2020?
* must provide value
No, your access to allergen-free food has not changed
Yes, you have had enough allergen-free food, but difficulty getting to the store or finding items
Yes, you have occasionally been without enough allergen-free food or good quality allergen-free food items
Yes, you have frequently been without enough allergen-free food
Have you been eating more in general or eating more processed food than normal since March 1, 2020?
* must provide value
No, there have been no changes, or you have been eating slightly less than usual
Yes, you have been eating slightly more than usual
Yes, you have been eating more frequently or more processed foods than usual
Yes, you have been eating much more frequently or have a significantly less healthy diet
Has your normal physical activity changed since March 1, 2020?
* must provide value
No, you do not normally exercise
No, you have been exercising with the same and intensity as you usually do
Yes, you have been exercising regularly, but with less intensity than usual
Yes, you have not been exercising as regularly as usual, but the intensity is the same as usual
Yes, you have not been exercising at all and are very sedentary
Has your access to medical care changed since March 1, 2020?
* must provide value
No, you have not tried to access care, or you haven't needed care since March 1, 2020
No, there have been no changes to your medical care
Yes, you have had mild changes, such as appointments moved to telehealth instead of in-person visits
Yes, you have had moderate changes, such as delays in your appointments or getting prescriptions with some impact on your health
Yes, you have had severe changes, you have been unable to access needed care with impact on your health
Has your access to mental health care changed since March 1, 2020?
* must provide value
No, you have not tried to access mental health care or you haven't needed care since March 1, 2020
No, there have been no changes to your mental health care
Yes, you have had mild changes, such as appointments moved to telehealth instead of in person visits
Yes, you have had moderate changes, such as delays in your appointments or getting prescriptions with some impact on your mental health
Yes, you have had severe changes, you have been unable to access needed care which has had an impact on your mental health
Has your access to extended family and trusted friends changed since March 1, 2020?
* must provide value
No, there has been no change
Yes, there have been mild changes, such as visits with social distancing or phone calls or social media
Yes, there have been moderate changes, with contact with some friends and family, but not all
Yes, there have been severe changes, with loss of contact with all my friends and family
Have you experienced stress related to the pandemic since March 1, 2020?
* must provide value
No, no stress at all
Yes, mild stress as occasional worries or minor stress related symptoms such as feeling a little anxious, sad, angry, or mild trouble sleeping
Yes, moderate stress with frequent worries, often feeling anxious, sad, or angry, with some trouble sleeping
Yes, severe stress with constant worries or feeling extremely anxious, sad, or angry, or frequent trouble sleeping
Have you experienced any stress or discord in your household?
* must provide value
No, none
Yes, household members occasionally short-tempered with one another but no physical violence
Yes, household members frequently short-tempered with one another or children in the same home getting in physical fights with one another
Yes, household members frequently short-tempered with one another and adults in the home throwing things at one another, knocking over furniture, hitting or harming one another
Since March 1, 2020 and because of the COVID -19 pandemic, have you practiced social distancing (reduced physical contact with people outside your home in social, work, or school settings by avoiding large groups and staying 3-6 feet away from other people when in public)?
* must provide value
Yes
No
For how long have you been socially distancing or did you social distance?
* must provide value
(number of days?)
Did you social distance to protect someone else in your household?
* must provide value
Yes
No
Of the days you practiced social distancing, how often did you end up needing to be near other people (how often were you unable to successfully practice social distancing)?
* must provide value
(number of days?)
Did you choose to be near other people or did someone else require you to?
* must provide value
Chose myself
Required by someone else
Since March 1, 2020, have you stayed home as much as possible?
* must provide value
Yes
No
For how long did you stay home as much as possible? (days)
* must provide value
(number of days?)
Did you stay home as much as possible to protect someone else in your household?
* must provide value
Yes
No
Of the days you tried to stay home, how many did you end up having to leave the home?
* must provide value
(number of days?)
Did you choose to leave your home yourself or did someone else require you to leave home?
* must provide value
Chose myself
Required by someone else
Have you self-isolated or quarantined? (ie separated from other people, even those in your own household, to keep them from getting sick)
* must provide value
Yes, because you had symptoms or were sick
Yes, because you tested positive for coronavirus
Yes, because you were exposed to a known case
Yes, because you were exposed to a suspected case
Yes, because you were unsure of your infection status
No, I did not self-isolate or quarantine
For how long have you been doing this/for how long did you do this? (days)
* must provide value
(number of days?)
Did you do this to protect someone else in your household?
* must provide value
Yes
No
Of the days when you practiced self-isolation, how many days did you end up breaking self-isolation or quarantine?
* must provide value
(number of days?)
Have you cared for a dependent/dependents in your home? A dependent is anyone who relies on you for help with activities of daily living, including children under the age of 18 years, anyone over the age of 70 years, or someone with a chronic disease or disability.
* must provide value
Yes
No
Who did you care for?
* must provide value
Child/Children
Elderly (over the age of 70)
Someone with chronic disease or disability
Have you provided care in your home for someone with COVID-19?
* must provide value
Yes
No
Who did you care for? (Select all that apply)
* must provide value
Specify relation of other person:
* must provide value
Have you made any of the following changes to your life style or daily activities because of COVID-19? (Select all that apply)
* must provide value
Overall, considering all the possible ways your life may have been impacted by the COVID-19 pandemic, how much has the pandemic affected your day-to-day life?
* must provide value
It has not affected my life at all
It has affected my life a little
It has moderately affected my life
It has extremely impacted my life
Refuse to answer
When was the last time you had face to face (in person) contact with someone who lives outside your household? Face to face contact is defined as anyone you saw in person, even at a 6 foot distance.
* must provide value
(number of days?)
Who did you have face to face contact with? (Select all that apply)
* must provide value
Specify other:
* must provide value
When was the last time you left your house for any reason? (days)
* must provide value
(number of days?)
Is your life more lonely because of the COVID-19 pandemic?
* must provide value
Yes
No
Since the COVID-19 pandemic started on March 1, 2020, how safe do you feel in your neighborhood?
* must provide value
Very safe
Somewhat safe
Not very safe at all
Not safe at all
Don't know
Refuse to answer
Since the COVID-19 pandemic started on March 1, 2020, how safe do you feel inside your home?
* must provide value
Very safe
Somewhat safe
Not very safe at all
Not safe at all
Don't know
Refuse to answer
Since the COVID-19 pandemic started on March 1, 2020, do you feel more or less safe inside your home?
* must provide value
Less safe
The same
More safe
Since the COVID-19 pandemic started on March 1, 2020, has the frequency of the behaviors in the last 2 questions: increased, decreased, or stayed the same?
* must provide value
Increased
Decreased
Stayed the same
Don't know
Refuse to answer
Since the COVID-19 pandemic started on March 1, 2020, I have been able to get allergen free foods when I need them?
* must provide value
Yes
No
I have not tried to get allergen free foods
Don't know
Refuse to answer
Has COVID-19 related social distancing had an impact had an impact on your food allergy lifestyle?
* must provide value
Yes
No
If yes, please specify:
* must provide value