Baltimore Anonymous Community COVID Survey
CLARIFICATION: THIS SURVEY IS MEANT ONLY FOR PEOPLE WITH SYMPTOMS, CONFIRMED POSITIVE TESTING, OR WHO SUSPECT THEY HAVE OR HAD COVID INFECTION. IT IS NOT MEANT FOR HEALTHY AND UNEXPOSED/UNTESTED INDIVIDUALS.

ONE FORM FOR EACH MEMBER OF THE FAMILY. After submitting, you can click "Submit Another Response" to fill out a new form for each affected family member.

This survey is to help track cases, stop communal spread, and aid clinicians in preparing for community health needs.

All information provided is STRICTLY CONFIDENTIAL AND ANONYMOUS and is only being used to help the community stay safe and stop the spread of the virus.

Thank you for your assistance in this crucial task.
Do you understand that this survey is only for people with symptoms of COVID, confirmed COVID testing, or suspected COVID?
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Have you filled this form out before and this is an update on change of symptoms or care needed? *
What is your gender? *
Please provide your birth date. *
The date will be used as your survey number, when you submit updates and will be kept strictly confidential.
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What street do you live on?
This is voluntary, but would be extremely helpful in identifying infection clusters
What are the last 4 digits of the phone number of the primary family member filling out this form? (You can also use any random 4 digits, so long as all family members in one household use the same number. This helps us understand which forms belong to the same family, without identifying the family. Please have all family members in the same home use the same 4 digits.) *
What is your zip code? *
Please check if you have any of the following:
Please check if you've had any of the following symptoms, please check as appropriate:
Around what date do you think the symptoms began? *
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For the above symptoms, how many days did symptoms last in total? (If you still have symptoms, indicate how many days thus far) *
How bad were your symptoms, on a scale from 1 (very mild) to 10 (quite severe)? *
What places had you been in the fourteen days prior to the start of symptoms (check all that apply) ? *
Required
Did you have close contact with someone that had COVID in the 14 days prior to your symptoms beginning? *
Have you been tested for COVID? (check all that apply) *
Required
Have all your symptoms resolved? *
If you no longer have symptoms, how many days has it been since you've NO LONGER had symptoms? (Not counting smell/taste)?
Were you hospitalized over night for COVID? *
Did you keep 6 feet apart from people outside your family (please check all that apply)? *
Always
Sometimes
Never
Before symptom onset
Currently
Did your family keep 6 feet apart from people outside your family (please check all that apply)? *
Always
Sometimes
Never
Before symptom onset
Currently
Did you wear a mask when outside your home? (please check all that apply) *
Always
Sometimes
Never
Prior to symptom onset
Currently
Did your family wear masks when outside your home? (please check all that apply) *
Always
Sometimes
Never
Prior to symptom onset
Currently
How many family members live in this household (total, including you)? *
How many family members got sick (including yourself)? (And PLEASE fill out a separate form for each one of them) ? *
Are you filling out this form for someone else? *
If the opportunity arises in the future, do you consent to use of this data for epidemiologic research purposes? All of your responses will still remain completely anonymous to researchers and be completely stripped of identifying information other than age and gender.
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