BrooklineCAN “Living with Covid-19” Survey Question Title * 1. How do you get information about the Covid19 pandemic? (check all that apply) Radio and/or television Printed Newspapers Various internet sources Signs posted in public places My health care provider BrooklineCAN and/or Senior Center Newsletter (print or digital) Friends, relatives, and neighbors OK Question Title * 2. Check all the activities in which you engaged at least once in the past month Had a housecleaner come into my home Had a caregiver come into my home Had a friend or relative come into your home to visit Went out to shop for groceries Went out to shop at a pharmacy Got a haircut at a salon or barber shop Exercised at a gym or fitness studio Attended a religious service Went to a park Sat on a bench in a park or along a sidewalk Picked up take-out food at a restaurant Ate a meal at an outdoor restaurant Ate a meal indoors at a restaurant Rode in an automobile with someone who does not live in my household Rode on a MBTA bus or subway Rode on MBTA “The Ride” Traveled outside of New England Did paid work away from home Did volunteer work away from home OK Question Title * 3. In the past 3 months, have you (check all that apply) Had a face-to-face meeting with a health care provider (including dentist) Had a remote medical consultation by telephone without any video Had a remote medical consultation with a video Needed to see a health care provider but was not able to get an appointment Had a medical appointment canceled because of COVID-19 OK Question Title * 4. When are you making regular use of a face mask or face covering? (Check all that apply) When at home with others in my household Whenever outdoors Whenever outdoors and other people are close by Whenever indoors with people who do not live my household Whenever riding on a bus or subway Whenever riding in an automobile with others who do not live in my household OK Question Title * 5. How comfortable are you in wearing a face mask or face covering? Comfortable Somewhat uncomfortable Very uncomfortable OK Question Title * 6. Do you have a medical condition that makes it difficult for you to use a face mask or face covering? Yes No OK Question Title * 7. Since the start of the Covid-19 restrictions, are you spending more time at home on the following (check all that apply)? Talking to friends and relatives on the phone Reading Taking on-line classes Doing puzzles Playing games Watching television Using a computer House cleaning Cooking Exercising Doing paid work Doing volunteer work OK Question Title * 8. If you were to test positive for Covid-19, do you have someone to take care of you? Yes No OK Question Title * 9. How do you rate your health? Excellent Good Fair Poor OK Question Title * 10. In the past 6 months, has there been a change in your health? Improved No change Declined OK Question Title * 11. To what extent are you able to carry out your everyday physical activities such as walking, climbing stairs, carrying groceries, or moving a chair? Completely Mostly Moderately A little Not at all OK Question Title * 12. Since Covid-19 restrictions were announced last March, has there been a change in how often you feel lonely or isolated from those around you? I feel lonely or isolated LESS often The has been NO CHANGE in how often I feel lonely or isolated I feel lonely or isolated MORE often OK Question Title * 13. Since Covid-19 restrictions were announced in March, has there been a change in how often you have been bothered by emotional problems such as feeling anxious, depressed, or irritable? I feel anxious, depressed, or irritable LESS often The has been NO CHANGE in how often I feel anxious, depressed, or irritable I feel anxious, depressed, or irritable MORE often OK Question Title * 14. Since Covid-19 restrictions were announced in March, has there been a change in how often you have been unable to stop or control worrying I am Less often able to stop or control worrying There has been no change in how often I worry I am more often unable to stop or control worrying OK Question Title * 15. Since Covid-19 restrictions were announced in March, has there been a change in how often you have had little interest or pleasure in doing things? There have been fewer times when I had little interest in doing things. There has been no change in the number of times when I had little interest in doing things. There have been more times when I had little interest in doing things. OK Question Title * 16. Are you in a high-risk group for Covid-19 because of one or more chronic health problems? Yes Not sure No OK Question Title * 17. Do you have a computer or tablet at home with internet access? Yes No OK Question Title * 18. Do you have a smartphone? Yes No OK Question Title * 19. If yes, how satisfied are you with your skills in using the apps on your smartphone? Very satisfied Somewhat satisfied Somewhat dissatisfied Very dissatisfied OK Question Title * 20. In the past 3 months, have you participated in a remote meeting using Zoom or another conference software either with a phone or video connection Yes No OK Question Title * 21. If yes, how satisfied are you with your skills in using Zoom or other conference software? Very satisfied Somewhat satisfied Somewhat dissatisfied Very dissatisfied OK Question Title * 22. Do you know someone who has been diagnosed with Covid-19? Yes No OK Question Title * 23. Have you tested positive for Covid-19 Yes No OK Question Title * 24. What is your age? Under 60 60 – 69 70 -79 80 – 89 90 and over OK Question Title * 25. With what gender do you identify: Female Male Non-binary/third gender Prefer not to say OK Question Title * 26. Where do you live? Brookline, Massachusetts Somewhere else in the Boston metropolitan area Outside of the Boston metropolitan area OK Question Title * 27. Including yourself, how many people live in your household? OK Question Title * 28. Do you live in some form of senior housing? Yes No OK Question Title * 29. Are you Spanish, Hispanic, or Latino? Yes No OK Question Title * 30. What is your race? (Check one or more) Native American or Alaskan native Asian, Asian Indian, or Pacific Islander Black or African American White Other OK Question Title * 31. What is your employment status? (Check one) Employed full time Employed part time Unemployed, looking for work Unemployed, not looking for work Homemaker or caregiver Retired Other OK Question Title * 32. Which category best describes your household income before taxes last year? Less than $25,000 $25,000 to $49,999 $50,000 to $99,999 $100,000 to $199,999 $200,000 to $299,999 $300,000 and over OK Question Title * 33. How worried are you about having enough money to pay your bills? Not at all worried A little worried Somewhat worried Very worried Extremely worried OK Question Title * 34. Since the start of the Covid-19 pandemic, has your overall financial situation become better, stayed the same, or become worse: My financial situation has improved My financial situation has stayed the same. My financial situation has become worse. OK SUBMIT
