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ROTA – Long Covid Research Project Questionnaire
1.
What is your age?
17 years or under
18-29 years
30-39 years
40-49 years
50-59 years
60-69 years
70-79 years
80+ years
Prefer not to say
2.
Are you:
Male
Female
Prefer not to say
3.
Do you have any dependents?
Yes
No
4.
What is your ethnic group or background?
Caribbean
West African
East African
South African
Central African
Mixed (any combination of the previously mentioned groups)
Mixed (any of the previous groups and White)
Mixed (any of the previous groups and a group not mentioned)
Other (please specify)
5.
What is your current work status?
Working full-time
Working part-time
Not working because of COVID-19
Not working because of other reasons
Studying full time
Studying and working
Retired
Other (please specify)
6.
What is your household income?
Below £20,000
£20,000 - £30,000
£30,001 - £40,000
£40,001 - £70,000
Above £70,000
Prefer not to say
7.
Which region does your main residence fall within?
North East
North West
Yorkshire and Humberside
East Midlands
West Midlands
London
South East
South West
Wales
Scotland
Northern Ireland
Other
I prefer not to say
8.
Have you had Covid 19?
Yes
No
9.
If Yes, did you:· Self-treat at home, Receive treatment in hospital but not intensive care, Receive treatment in intensive care? (write your answer below)
Current Progress,
0 of 31 answered
