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1. What are you doing/did you do during COVID-19 (coronavirus)? (check all that apply)
Kisa w ap fè/kisa w te fè pandan pandemi COVID-19 (kowonaviris) (make tout repons ki aplikab)
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__ no changes to my life or behavior
___ M pa t chanje anyen nan lavi mwen oubyen nan konpòtman m
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__ practicing social distancing (i.e., reducing your physical contact with other people in social, work, or school settings by avoiding large groups and staying 3-6 feet away from other people)
__ M ap pratike distans sosyal (kenbe distans ou ak lòt moun nan lavi sosyal w, nan travay w, oubyen nan lekòl w, evite gwo rasanbleman, rete yon distans 3-6 pye lòt moun)
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(if yes, how long have you been doing/did you do this for? _____ [days])
Of these _____ days, how many did you end up needing to be physically near people (i.e., you were not able to practice social distancing on those days)? _____ [days]
(if yes, did you choose to do this yourself or did someone else require you to? _____Y/N)
(if yes, did you do this to protect someone else in your household? _____Y/N)
(si w reponn wi – pandan konbyen jou w ap fè/ou t ap fè sa? _____ [jou])
Pami _____ jou sa yo, pandan konbyen jou ou te blije kole sere lòt moun (sa vle di, ou pa t kapab pratike distans sosyal pandan jou sila yo)? _____ [jou])
(si w reponn wi – èske w chwazi fè sa [pratike distans sosyal], ou menm, oubyen èske gen yon
lòt moun [pa egzanp, yon fanmi w, patwon w, leta, elatriye] ki egzije w fè sa? _____oui/non)
(si w reponn wi – èske w fè sa [izole tèt ou oubyen rete nan karantèn] pou pwoteje yon lòt moun nan
kay w? _____oui/non)
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__ isolating or quarantining yourself (i.e., while you are sick or if you have been exposed, separating yourself from other people to prevent others from getting it)
__ M mete tèt mwen nan izolasyon oubyen nan karantèn (pandan ou malad oubyen si w espoze, pran distans ou avèk lòt moun pou anpeche lòt moun trape maladi a)
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(if yes, how long have you been doing/did you do this for? _____ [days])
Of these _____ days, how many did you end up end up breaking the isolation or
quarantine (i.e., you were not isolated or quarantined on those days)? ____ [days]
(if yes, did you choose to do this yourself or did someone else require you to? _____Y/N)
(if yes, did you do this to protect someone else in your household? _____Y/N)
(si w reponn wi, pandan konbyen jou w ap fè/ou t ap fè sa? _____ [jou])
Pami _____ jou sa yo, pandan konbyen jou ou resi sispann fè izolasyon oubyen karantèn (sa vle di, ou pa t izole oubyen sou karantèn pandan jou sila yo? _____ jou)
(si w reponn wi, èske w chwazi fè sa [pratike distans sosyal], ou menm, oubyen èske gen yon lòt moun [pa egzanp, yon fanmi w, patwon w, leta, elatriye] ki egzije w fè sa? _____oui/non)
(si w reponn wi, èske w fè sa [izole tèt ou oubyen rete nan karantèn] pou pwoteje yon lòt moun nan kay w? ____oui/non)
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__ caring for someone at home
__ M te blije okipe lòt moun nan fanmi an
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(if yes,
__ a child or children
__ an elderly person
__ a person with a disability, or someone else under your care)
(si ou reponn wi,
__ yon oubyen plizyè timoun
__ yon ti granmoun
__ yon moun ki andikape, oubyen yon lòt moun ki sou kont ou)
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__ working from home
___ M ap fè djòb m te konn fè a, pandan m ap chita lakay mwen
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(if yes, did you have to balance this with taking care of others [e.g., parents, kids, partners? _____Y/N)
(si w reponn wi, èske w te bije degaje w travay pandan w ap okipe lòt moun, pa egzanp manman w, papa w, pitit ou, mari w, madam ou? _____oui/non)
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__ not working
__ M pa travay
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(if yes, did you lose your source of income because of COVID-19/coronavirus? _____Y/N)
(if yes, why? (check all that apply)
__ because I am/was sick or under quarantine
__ because someone in my household was sick/under quarantine
__ because my place of work was closed and didn’t offer a remote work option
__ because I was laid off or lost my employment
(si w reponn wi, èske w pèdi sous revni w akòz COVID-19/kowonaviris? _____oui/non)
(si w reponn wi, poukisa? make tout sa ki aplikab)
__ paske mwen malad/mwen te malad oubyen m te sou karantèn
__ paske gen moun nan kay mwen ki te malad/sou karantèn
__ paske kote m t ap travay la fèmen epi yo pa t bay yon opsyon pou nou travay
__ paske yo revoke m/m pèdi djòb mwen
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__ a change in use of healthcare services (e.g., calling your healthcare provider, going to urgent care, etc.)
__ M chanje jan m itilize sèvis swen sante (pa egzanp, ou rele doktè a nan telefòn, ou ale nan klinik kote ou pa bezwen fè randevou davans [Urgent Care Center], elatriye)
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(if yes, was this an increase or decrease? ____ increase ____ decrease)
(si w reponn wi, èske w itilize sèvis sila yo pi souvan oubyen mwen souvan? _____pi souvan _____mwen souvan)
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__ following media coverage related to COVID-19 (e.g., watching or reading the news, following social media coverage, etc.)
__ M ap swiv medya sou COVID-19 (pa egzanp, gade oubyen li nouvèl, swiv sa k ap pase sou rezo sosyo)
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(if yes: on average, how many hours per day did you spend on this? _____ [hours])
(si w reponn wi: an mwayèn, konbyen èdtan ou fè sa chak jou? _____ [hours])
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__ changing travel plans
__ chanje plan vwayaj w
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(if yes, did you travel more or less? ____ more ____ less)
(si w reponn wi, èske vwayaje plis oubyen mwens? ____plis ____mwens)
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2. How much is/did COVID-19 (coronavirus) impact your day-to-day life?
Nan ki degre COVID-19 (kowonaviris) fè efè sou lavi kotidyen w an?
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1. Not at all / Pa ditou
2. A little / Yon ti kal
3. Much / Anpil
4. Very Much / Anpil anpil
5. Extremely / Estrèmeman
6. Decline to Answer /M pa vle reponn
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3. With of the following are you experiencing (or did you experience) during COVID-19 (coronavirus)? (check all that apply)
Ki eksperyans w ap viv aktyèlman (oubyen ki eksperyans ou viv deja) pandan pandemi COVID-19 (kowonaviris) la? (Make tout repons ki aplikab)
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__ being diagnosed with COVID-19
__ M trape kowonaviris mwen menm (m fè dyagnostik; rezilta a te pozitif)
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__ fear of getting COVID-19
__ M pè pran kowonaviris
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__ fear of giving COVID-19 to someone else
__ Mwen pè pase kowonaviris bay lòt moun
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__ worrying about friends, family, partners, etc.
__ M enkyete pou zanmi, fanmi, mari, madam, mennaj, elatriye
(if yes:
__ locally
__ in other parts of the US
__ outside the US
(si ou reponn wi, èske w enkyete pou moun ki:
__ isit [Florid disid, lòt vil Laflorid]
__ lòt zòn Etazini
__ nan lòt peyi [pa Ozetazini] )
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__ stigma or discrimination from other people (e.g., people treating you differently because of your identity, having symptoms, or other factors related to COVID-19)
__ M ap sibi estigmatizasyon, diskriminasyon, oubyen pèsekisyon lòt moun (sa vle di: moun ki trete w diferan akòz idantite w, oubyèn paske ou gen sentòm, oubyen lòt faktè ki makonnen avèk COVID-19)
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__ personal financial loss (e.g., lost wages, job loss, investment/retirement loss, travel-related cancelations)
___ M ap pèdi lajan (pa egzanp, ou pèdi salè w, ou pèdi djòb ou, ou pèdi kòb ou envesti oubyen kòb ou te gen nan kès retrèt w, ou pèdi kòb paske w te blije anile yon vwayaj ou deja peye)
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__ frustration or boredom
___ M fistre, m santi m raz
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__ not having enough basic supplies (e.g., food, water, medications, a place to stay)
___ M pa gen ase founiti debaz (pa egzanp manje, dlo, medikaman, kote pou w rete)
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__ more anxiety
___ M gen kè sere
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__ more depression
__ M santi m pi deprime
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__ more sleep, less sleep, or other changes to your normal sleep pattern
___ M dòmi plis, m dòmi mwens, oubyen jan m dòmi chanje nan kèk lòt fason
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__ increased alcohol or other substance use
___ M ap bwè plis tafya/alkòl oubyen lòt sibstans/dwòg
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__ a change in sexual activity
___ M chanje onivo aktivite seksyèl
(if yes, was this an increase _____or decrease? _____ )
(si ou reponn wi, èske w gen relasyon seksyèl pi souvan? _____ Mwens souvan? _____ pi souvan?)
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__ loneliness
___ M santi m sèl
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__ confusion about what COVID-19 is, how to prevent it, or why social distancing/isolation/quarantines are needed
___ M santi m bwouye sou sa COVID-19 la ye, koman pou m fè prevansyon, oubyen poukisa li nesèsè pratike distans sosyal (kenbe distans ou ak lòt moun), fè izolasyon, osinon fè karantèn
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__ feeling that I was contributing to the greater good by preventing myself or others from getting COVID-19
___ M santi m ap bay kominote a yon koutmen paske m ap anpeche tèt mwen oubyen lòt moun trape COVID-19
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__ getting emotional or social support from family, friends, partners, a counselor, or someone else
___ M jwenn apwi moral oubyen sosyal nan men fanmi, zanmi, mari, madam, mennaj, yon konseye, oubyen lòt moun
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__ getting financial support from family, friends, partners, an organization, or someone else
__ M jwenn apwi finansye nan men fanmi, zanmi, mari, madam, mennaj, yon òganizasyon/enstans, oubyen lòt moun
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__ other difficulties or challenges (We want to hear from you! Please tell us more _____________________________
___________________________________________________________________________________________________________________
__ Lòt difikilte oubyen defi (Nou ta renmen tande kisa w ap viv! Tanpri, ba nou plis detay: __________________________
___________________________________________________________________________________________________________________
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