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