Description:

The CRISIS Survey is designed to enable the researchers and care providers to examine the extent and impact of life changes induced by the epidemic on the mental health and behavior of individuals and families across diverse international settings. Our hope is that such data will enable the identification of pre-, peri, and post-COVID19 demographic, social, and clinical predictors of both short- and long-term impairment and distress induced by COVID19 and its sequelae. The CRISIS can be used to track impact of the survey in diverse clinical, population and research settings. It may be even more informative for identifying predictors of impact and service needs from studies that have well characterized information from prior to COVID19. A broad range of behaviors and function are probed in the survey, including daily behaviors, emotional status, media usage, and substance use. The survey is designed to allow for follow-ups on a regular basis, with recommended frequencies of twice monthly or monthly. To facilitate multicultural perspectives, translations in a broad range of languages are available. Investigators: K. Merikangas, M. Milham, A. Stringaris Collaborators: E. Bromet, S. Colcombe, V. Zipunnikov The team encourages advanced notification of any media, scientific reports or publications of data that have been collected with the CRISIS (merikank@mail.nih.gov), though this is not required. We also encourage voluntary data sharing for the purpose of psychometric studies that will be led by Dr. Stringaris (argyris.stringaris@nih.gov).

Keywords:
  1. 2/6/22 2/6/22 - Dr. Christian Niklas
Copyright Holder:
Kathleen Merikangas and Argyris Stringaris at the National Institute of Mental Health Intramural Research Program Mood Spectrum Collaboration, and those of Michael P. Milham at the Child Mind Institute and the NYS Nathan S. Kline Institute for Psychiatric Research
Uploaded on:

February 6, 2022

DOI:
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License :
Creative Commons BY 4.0
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The CoRonavIruS Health Impact Survey (CRISIS) V0.3 - Adult Self-Report Baseline Form

Adult Selfreport Baseline Form

  1. StudyEvent: The CoRonavIruS Health Impact Survey (CRISIS) V0.3
    1. Adult Selfreport Baseline Form
Background
Country:
Please specify your sex:
England, Ireland, Scotland or Wales
Australia - not of Aboriginal or Torres Strait Islander descent
Australia - of Aboriginal or Torres Strait Islander descent
New Zealand - not of Maori descent
New Zealand - of Maori descent
Northern Europe including Sweden
Western Europe including France
Eastern Europe including Russia
Southern Europe including Italy
Middle East including Lebanon
Eastern Asia including China
South-East Asia including Thailand
South Asia including India
Polynesia
Africa
North America - not of First Nations
North America - of First Nations
Don't know
Are you of Hispanic or Latino descent - that is, Mexican, Mexican American, Chicano, Puerto Rican, Cuban, South or Central American or other Spanish culture or origin?
Have you served in the military?
Which best describes the area in which you live?
What is the highest level of education YOU completed?
Are any adults living in the home an ESSENTIAL WORKER (e.g., healthcare, delivery worker, store worker, security, building maintenance)?
Do they come home each day?
Are they a FIRST RESPONDER, HEALTHCARE PROVIDER or OTHER WORKER in a facility treating COVID-19?
Are you covered by health insurance?
In the 3 months prior to the Coronavirus/COVID-19 crisis in your area, did you or your family receive money from government assistance programs like welfare, Aid to Families with Dependent Children, General Assistance, or Temporary Assistance for Needy Families?
How would you rate your overall physical health?
Seasonal allergies
Asthma or other lung problems
Heart problems
Kidney problems
Immune disorder
Diabetes or high blood sugar
Cancer
Arthritis
Frequent or very bad headaches
Epilepsy or seizures
Serious stomach or bowel problems
Serious acne or skin problems
Emotional or mental health problems such as Depression or Anxiety
Problems with alcohol or drugs
Intellectual disability
Autism Spectrum Disorder
Learning Disorder
Measurement:
Measurement:
How would you rate your overall Mental/Emotional health before the Coronavirus/COVID-19 crisis in your area?
Exposure status last two weeks
have you been exposed to someone with positive SARS CoV 2 test?
have you been exposed to someone medical diagnosed with a SARS CoV 2 infection without positive test result?
have you been exposed to someone with possible COVID-19 symptoms during the past two weeks?
No
Yes, has positive test
Yes, medical diagnosis, but no test
Yes, have had some possible symptoms, but no diagnosis
Fever
Cough
Shortness of breath
Sore throat
Fatigue
Loss of taste or smell
Eye infection
Other
Yes, household member
Yes, non-household member
Fallen ill physically
Hospitalized
Put into self-quarantine with symptoms
Put into self-quarantine without symptoms
Lost or been laid off from job
Reduced ability to earn money
Passed away
...being infected?
...friends or family being infected?
...your physical health being influenced by Coronavirus/ COVID-19?
...your Mental/Emotional health being influenced by Coronavirus/ COVID-19?
How much are you reading or talking about Coronavirus/ COVID-19?
Has the Coronavirus/ COIVD-19 crisis in your area led to any positive change in your life?
Life changes last two weeks
...if you attend school, has your school building been closed?
Are classes in session?
Are you attending classes in-person?
Have classes resumed online?
Do you have easy access to the internet and a computer?
Are there assignments for you to complete?
Are you able to receive meals from the school?
...if you had a job prior to the Coronavirus/COVID-19, are you still working?
Are you still going to your workplace?
Are you teleworking or working from home?
Were you laid off from your job?
Did you lose your job?
...how much time have you spent going outside of the home (e.g., going to stores, parks, etc.)?
...how stressful have the restrictions on leaving home been for you?
...have your contacts with people outside of your home changed relative to before the Coronavirus/COVID-19 crisis in your area?
...how much difficulty have you had following the recommendations for keeping away from close contact with people?
...has the quality of the relationships between you and members of your family changed?
...how stressful have these changes in family contacts been for you?
...has the quality of your relationships with your friends changed?
...how stressful have these changes in social contacts been for you?
...how much has cancellation of important events (such as graduation, prom, vacation, etc.) in your life been difficult for you?
...to what degree have changes related to the Coronavirus/COVID-19 crisis in your area created financial problems for you or your family?
...to what degree are you concerned about the stability of your living situation?
...did you worry whether your food would run out because of a lack of money?
How hopeful are you that the Coronavirus/COVID-19 crisis in your area will end soon?
Daily behaviors past three month
...on average, what time did you go to bed on WEEKDAYS?
...on average, what time did you go to bed on WEEKENDS?
...on average, how many hours per night did you sleep on WEEKDAYS?
...on average, how many hours per night did you sleep on WEEKENDS?
...how many days per week did you exercise (e.g., increased heart rate, breathing) for at least 30 minutes?
...how many days per week did you spend time outdoors?
Emotions/ Worries past three month
...how worried were you generally?
...how happy versus sad were you?
...how much were you able to enjoy your usual activities?
...how relaxed versus anxious were you?
...how fidgety or restless were you?
...how fatigued or tired were you?
...how well were you able to concentrate or focus?
...how irritable or easily angered were you?
...how lonely were you?
...to what extent did you have negative thoughts, thoughts about unpleasant experiences or things that made you feel bad?
Media use past three month
...watching TV or digital media (e.g., Netflix, YouTube, web surfing)?
...using social media (e.g., Facetime, Facebook, Instagram, Snapchat, Twitter, TikTok)?
...playing video games?
Substance use past three month
...alcohol?
...vaping products?
...cigarettes or other tobacco products?
...marijuana/cannabis (e.g., joint, blunt, pipe, bong)?
...opiates, heroin, or narcotics?
...other drugs including cocaine, crack, amphetamine, methamphetamine, hallucinogens, or ecstasy?
...sleeping medications or sedatives/hypnotics?
Daily behaviors past two weeks
...on average, what time did you go to bed on WEEKDAYS?
...on average, what time did you go to bed on WEEKENDS?
...on average, how many hours per night did you sleep on WEEKDAYS?
...on average, how many hours per night did you sleep on WEEKENDS?
...how many days per week did you exercise (e.g., increased heart rate, breathing) for at least 30 minutes?
...how many days per week did you spend time outdoors?
Emotions/ Worries past two weeks
...how worried were you generally?
...how happy versus sad were you?
...how much were you able to enjoy your usual activities?
...how relaxed versus anxious were you?
...how fidgety or restless were you?
...how fatigued or tired were you?
...how well were you able to concentrate or focus?
...how irritable or easily angered were you?
...how lonely were you?
...to what extent did you have negative thoughts, thoughts about unpleasant experiences or things that make you feel bad?
Media use past two weeks
...watching TV or digital media (e.g., Netflix, YouTube, web surfing)?
...using social media (e.g., Facetime, Facebook, Instagram, Snapchat, Twitter, TikTok)?
...playing video games?
Substance use past two weeks
...alcohol?
...vaping products?
...cigarettes or other tobacco products?
...marijuana/cannabis (e.g., joint, blunt, pipe, bong)?
...opiates, heroin, or narcotics?
...other drugs including cocaine, crack, amphetamine, methamphetamine, hallucinogens, or ecstasy?
...sleeping medications or sedatives/hypnotics?
Which of the following supports were in place for you before the Coronavirus/COVID-19 crisis in your area and have been disrupted over the PAST TWO WEEKS? (check all that apply)
Resource room
Tutoring
Mentoring programs
After school activity programs
Volunteer programs
Psychotherapy
Psychiatric care
Occupational therapy
Physical therapy
Speech/language therapy
Sporting activities
Medical care for chronic illnesses
Other
additional concerns and comments
Comment section - Adult Selfreport Baseline Form

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