RISCOVID Customized Form Tool

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- title: COVID Disclosure Formulaire - text: - Everything in this questionnaire is optional. Choose to disclose anything you think it will make the people you are meeting more comfortable. - No information is sent out. Tis is an off-line form. Once you are finished, you can get a summary of your answers to send out (that requires to run some local JavaScript) or you can print to PDF the completed questionnaire. - summary: Summary - summarize: Summarize - hoax: caption: 'Do you think the SARS-CoV-2 ("coronavirus" or "COVID") is a hoax (i.e., there is no virus)?' options: - text: Yes. gloss: I believe there is no virus. - text: No. gloss: "" postscript: (If yes, no need to fill up the rest! Thanks for the heads up.) - care: caption: How much do you care about not catching the SARS-CoV-2 virus? options: - text: Very much. gloss: I care a lot about SARS-CoV-2. - text: I care. gloss: I care about SARS-CoV-2. - text: Somewhat. gloss: SARS-CoV-2 is important to me. - text: Not much. gloss: SARS-CoV-2 is not important to me. - text: I don't care. gloss: I don't care about SARS-CoV-2. - carefor: caption: Are there people in your household you care not to get infected? options: - text: Yes. gloss: There is a person in my household I care for them not to get infected. - text: No. gloss: "" extra: text: If yes, who? (You can disclose this for people to share your concern for your loved one and better understand your need for them to wear face masks, etc). I worry about my gloss: I care not to get infected to keep the health of my - size: caption: How many people are in your household (including yourself)? options: - text: More than 5. gloss: At home, we are more than five people. - text: 3-5 gloss: At home, we are between three to five people. - text: 2. gloss: We are two people at home. - text: 1. gloss: At home, it is only me. - bubble: caption: How many people would you estimate are in the "social bubble" of your household (people seen by somebody in your household, including yourself, at least once a month)? options: - text: More than 50. gloss: Our social bubble is humongous. - text: 12-50. gloss: Our social bubble is big. - text: 6-12. gloss: Our social bubble is decent. - text: 1-5. gloss: We keep to ourselves. - text: Just us. gloss: We see nobody else. - outside: caption: Is there anybody in your household (including yourself) that works outside your home? options: - text: Yes. gloss: We have people that work outside the home. - text: No. gloss: Nobody works outside the home. - classes: caption: Is there any person in your household (including yourself) that attends in-person classes (or children in daycare)? options: - text: Yes. gloss: We have people at school or daycare. - text: No. gloss: Nobody is at school or daycare. - iwear: caption: If you meet people socially, do you wear a face mask? options: - text: Always. gloss: If I meet people, I always wear a face mask. - text: Depends who I meet. gloss: Depending who I meet, I wear a face mask. - text: Depends on the place we meet. gloss: Depending where we are meeting, I wear a face mask. - text: Never. gloss: I never wear a face mask when I socialize. - uwear: caption: If you meet people socially, do you expect others to wear a face mask? options: - text: Always. gloss: If I meet people, I always expect them to wear a face mask. - text: Depends who I meet. gloss: Depending who I meet, I expect them to wear a face mask. - text: Depends on the place we meet. gloss: Depending where we are meeting, I expect them to wear a face mask. - text: Never. gloss: I never expect others to wear a face mask when I socialize. - transit: caption: How often does any person in your household (including yourself) takes mass transit (choose the answer for the most frequent traveler)? options: - text: Daily. gloss: There is somebody at home that takes mass transit daily. - text: Once a week. gloss: There is somebody at home that takes mass transit once a week. - text: Once a month. gloss: There is somebody at home that takes mass transit once a month. - text: Haven't used it since pandemic started. gloss: We haven't used mass transit since the start of the pandemic. - flight: caption: Have anybody in your household (including yourself) been in an airplane in the last two weeks? options: - text: Yes. gloss: Somebody has been on an airplane in the last two weeks. - text: No. gloss: Nobody has been on an airplane recently.

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