Gender | ( ) Female ( ) Male ( ) Do not wish to inform |
Age |
|
Type of Impairment | ( ) Hearing ( ) Hearing-visual ( ) Hearing-motor ( ) Other |
Municipality | ( ) Niterói ( ) São Gonçalo ( ) Rio Bonito ( ) Itaboraí ( ) Silva Jardim ( ) Tanguá |
How do you define your knowledge regarding the COVID-19 disease? | ( ) Don’t know what it is ( ) Very little knowledge ( ) A lot of knowledge |
If affirmative, what was your source of information regarding the COVID-19 disease? | ( ) Social Media ( ) Magazine/newspaper ( ) Videos ( ) Other ( ) Does not apply |
How do you evaluate how much social distancing has impacted your life? | ( ) Didn’t submit to social distancing ( ) It has not impacted my life ( ) It has impacted a little ( ) It has impacted a lot |
If affirmative, in which way did it impact the most (mark the most significant alternative) | ( ) Job Loss ( ) Difficulty communicating through masks ( ) Difficulty in health care ( ) Difficulty keeping up with physical exercises and/or physical therapy ( ) Lack of information about the disease ( ) Impact on mental health ( ) Other ( ) Does not apply |
Did you test positive for COVID-19? | ( ) Yes ( ) No ( ) I don’t know |
Did you have contact/take care of any relative or friend with COVID-19? | ( ) Yes ( ) No |