Questionnaire of the Canadian COVID-19 Antibody and Health Survey wave 3 (CCAHS) / Child
For Information onlyThis is an electronic survey example for information purposes only. This is not a working questionnaire.
Table of Contents
- Verification (DBS)
- Chronic conditions 1 (CHR)
- Chronic conditions 2 (CAN)
- Symptoms and COVID-19 status (CS)
- Risk for acquisition and risk factors (RA)
- Health behaviour changes related to COVID-19 (HB)
- Health assessment 1 (FLU)
- Health assessment 2 (HR)
- Health assessment 3 (GEN)
- Health assessment 4 (HWT)
- Demographic questions 1 (GDR)
- Demographic questions 3 (HHC)
- Demographic questions 4 (DW)
- Demographic questions 5 (DWL)
- Demographic questions 6 (ED)
- Indigenous identity (FN)
- Sociodemographic characteristics 1 (PG)
- Sociodemographic characteristics 2 (FNS)
- Vaccination 1 (VX)
- Vaccination 2 (DIR)
- Linking and sharing questions 1 (LNK)
- Linking and sharing questions 2 (HN)
- Linking and sharing questions 3 (SHR)
- Linking and sharing questions 4 (TAX)
- COVID test procedure and consent (CON)
- Test and contact information 1 (TST)
- Test and contact information 2 (NAD)
- Test and contact information 3 (EA)
- Test and contact information 4 (CEL)
- Re-contact (FUP)
Verification (DBS)
Verification (DBS) - Question identifier:DBS_R01
Before we start, we need to ask about this child's current health and physical conditions.
Verification (DBS) - Question identifier:DBS_Q51
Does this child have a blood clotting condition such as haemophilia or Von Willebrand disease?
- 1: Yes
- 2: No
Verification (DBS) - Question identifier:DBS_Q52
Has this child received chemotherapy in the past four weeks?
- 1: Yes
- 2: No
Chronic conditions 1 (CHR)
Chronic conditions 1 (CHR) - Question identifier:CHR_R01
The next question is about long-term health conditions. These are conditions which are expected to last or have already lasted 6 months or more and that have been diagnosed by a health professional.
Chronic conditions 1 (CHR) - Question identifier:CHR_Q25
Does this child have any of the following long term health conditions that have been diagnosed by a health care professional?
- 01: Chronic lung conditions (e.g., emphysema or bronchitis)
- 02: Asthma
- 03: Chronic heart disease
- 04: Diabetes
- 05: Chronic kidney disease
- 06: Liver disease (e.g., chronic hepatitis)
- 07: High blood pressure
- 08: Chronic blood disorder
- 09: A weakened immune system (e.g., due to disease or medication)
- 10: Chronic neurological disorder
- 13: None of the above
Chronic conditions 2 (CAN)
Chronic conditions 2 (CAN) - Question identifier:CAN_Q30
Has this child ever been diagnosed with cancer?
- 1: Yes
- 2: No
- 9: DK
Symptoms and COVID-19 status (CS)
Symptoms and COVID-19 status (CS) - Question identifier:CS_Q05
Do you think that this child has ever had COVID-19?
- 1: Yes
- 2: No
- 9: DK
Symptoms and COVID-19 status (CS) - Question identifier:CS_Q15
In the past six months, did this child ever have any of the following symptoms?
- 01: Cough
- 02: Fever
- 03: Chills
- 04: Sore throat
- 05: Shortness of breath or difficulty breathing
- 06: Pain (e.g., muscular, chest, abdominal, joint)
- 07: Runny nose (Exclude seasonal allergies)
- 08: Nausea, vomiting or diarrhea
- 09: Headache
- 10: General weakness
- 11: New loss of taste or smell
- 12: None of the above
Symptoms and COVID-19 status (CS) - Question identifier:CS_Q20A
Of the symptoms reported in the last six months, when was this child's first symptom?
Time of month
- 1: Early
- 2: Mid
- 3: Late
Symptoms and COVID-19 status (CS) - Question identifier:CS_Q20B
Month
- 01: January
- 02: February
- 03: March
- 04: April
- 05: May
- 06: June
- 07: July
- 08: August
- 09: September
- 10: October
- 11: November
- 12: December
Symptoms and COVID-19 status (CS) - Question identifier:CS_Q20C
Year
- 1: 2020
- 2: 2021
Symptoms and COVID-19 status (CS) - Question identifier:CS_Q25
Has this child ever had a nasal or throat swab to test for COVID-19?
- 1: Yes
- 2: No
Symptoms and COVID-19 status (CS) - Question identifier:CS_Q30
How many times have they been tested?
Number of times
Min = 0; Max = 99
Symptoms and COVID-19 status (CS) - Question identifier:CS_Q35
Has this child ever had a positive test result?
- 1: Yes
- 2: No
- 3: Waiting for results
Symptoms and COVID-19 status (CS) - Question identifier:CS_Q40
Was this child hospitalized for COVID-19?
- 1: Yes
- 2: No
Symptoms and COVID-19 status (CS) - Question identifier:CS_Q45A
When was this child's positive COVID-19 test taken?
Day
- 01: 1
- 02: 2
- 03: 3
- 04: 4
- 05: 5
- 06: 6
- 07: 7
- 08: 8
- 09: 9
- 10: 10
- 11: 11
- 12: 12
- 13: 13
- 14: 14
- 15: 15
- 16: 16
- 17: 17
- 18: 18
- 19: 19
- 20: 20
- 21: 21
- 22: 22
- 23: 23
- 24: 24
- 25: 25
- 26: 26
- 27: 27
- 28: 28
- 29: 29
- 30: 30
- 31: 31
Symptoms and COVID-19 status (CS) - Question identifier:CS_Q45B
Month
- 01: January
- 02: February
- 03: March
- 04: April
- 05: May
- 06: June
- 07: July
- 08: August
- 09: September
- 10: October
- 11: November
- 12: December
Symptoms and COVID-19 status (CS) - Question identifier:CS_Q45C
Year
- 1: 2020
- 2: 2021
Symptoms and COVID-19 status (CS) - Question identifier:CS_Q50
Has this child had any other positive test results for COVID-19?
- 1: Yes
- 2: No
Symptoms and COVID-19 status (CS) - Question identifier:CS_Q55A
When was the second positive COVID-19 test?
Day
- 01: 1
- 02: 2
- 03: 3
- 04: 4
- 05: 5
- 06: 6
- 07: 7
- 08: 8
- 09: 9
- 10: 10
- 11: 11
- 12: 12
- 13: 13
- 14: 14
- 15: 15
- 16: 16
- 17: 17
- 18: 18
- 19: 19
- 20: 20
- 21: 21
- 22: 22
- 23: 23
- 24: 24
- 25: 25
- 26: 26
- 27: 27
- 28: 28
- 29: 29
- 30: 30
- 31: 31
Symptoms and COVID-19 status (CS) - Question identifier:CS_Q55B
Month
- 01: January
- 02: February
- 03: March
- 04: April
- 05: May
- 06: June
- 07: July
- 08: August
- 09: September
- 10: October
- 11: November
- 12: December
Symptoms and COVID-19 status (CS) - Question identifier:CS_Q55C
Year
- 1: 2020
- 2: 2021
Symptoms and COVID-19 status (CS) - Question identifier:CS_Q60
Why did this child get tested?
- 01: Showing symptoms
- 02: Recent exposure to someone not living with this child who either had symptoms or had a confirmed infection with the virus that causes COVID-19
- 03: Recent exposure to someone living with this child who either had symptoms or had a confirmed infection with the virus that causes COVID-19
- 04: Recent international travel
- 05: I am a healthcare worker with direct patient contact (Include personal care worker and first responder.)
- 06: I am not a healthcare worker, but my work exposes me to the public (Include grocery or retail store worker, bus driver.)
- 07: Recent exposure at school or daycare
- 08: Did not have any symptoms but had concerns of infecting others
- 09: Other
Symptoms and COVID-19 status (CS) - Question identifier:CS_Q65
Why has this child never been tested for COVID-19?
- 01: Has never had symptoms
- 02: Testing unavailable or difficult to access
- 03: Getting tested is inconvenient and time-consuming
- 04: Takes too long to get results
- 05: Afraid of getting an infection from the virus that causes COVID-19 from testing site
- 06: Worried about impact of a positive result (e.g., on work, school, or social life)
- 07: Do not trust that results are kept confidential
- 08: Fear of blame for spreading COVID-19 if test is positive
- 09: Afraid of test procedure
- 10: Other
Symptoms and COVID-19 status (CS) - Question identifier:CS_Q70
Did you ever consider getting this child tested for COVID-19 but didn't?
- 1: Yes
- 2: No
Symptoms and COVID-19 status (CS) - Question identifier:CS_Q75
When you considered testing for this child, which of the following situations applied?
- 01: Showing symptoms
- 02: Recent exposure to someone not living with this child who either had symptoms or had a confirmed infection with the virus that causes COVID-19
- 03: Recent exposure to someone living with this child who either had symptoms or had a confirmed infection with the virus that causes COVID-19
- 04: Recent international travel
- 05: I am a healthcare worker with direct patient contact (Include personal care worker and first responder.)
- 06: I am not a healthcare worker, but my work exposes me to the public (Include grocery or retail store worker, bus driver.)
- 07: Recent exposure at school or daycare
- 08: Did not have any symptoms but had concerns of infecting others
- 09: Other
Risk for acquisition and risk factors (RA)
Risk for acquisition and risk factors (RA) - Question identifier:RA_Q05
Has this child travelled outside of their home province since March 1, 2020?
- 1: Yes, but stayed within Canada
- 2: Yes, went outside of Canada
- 3: No
Health behaviour changes related to COVID-19 (HB)
Health behaviour changes related to COVID-19 (HB) - Question identifier:HB_Q20A
Which of the following precautions is your family taking as protection against COVID-19?
Wash hands often
- 1: Always
- 2: Often
- 3: Occasionally
- 4: Never
- 5: Not applicable
Health behaviour changes related to COVID-19 (HB) - Question identifier:HB_Q20B
Which of the following precautions is your family taking as protection against COVID-19?
Wear a mask in indoor public spaces where physical distancing is difficult or a mandatory mask by-law exists
- 1: Always
- 2: Often
- 3: Occasionally
- 4: Never
- 5: Not applicable
Health behaviour changes related to COVID-19 (HB) - Question identifier:HB_Q20C
Which of the following precautions is your family taking as protection against COVID-19?
Wear a mask in outdoor public places where physical distancing is difficult or required
- 1: Always
- 2: Often
- 3: Occasionally
- 4: Never
- 5: Not applicable
Health behaviour changes related to COVID-19 (HB) - Question identifier:HB_Q20D
Which of the following precautions is your family taking as protection against COVID-19?
Keep a 2 meter or 6 foot distance from others
- 1: Always
- 2: Often
- 3: Occasionally
- 4: Never
- 5: Not applicable
Health behaviour changes related to COVID-19 (HB) - Question identifier:HB_Q20E
Which of the following precautions is your family taking as protection against COVID-19?
Avoid crowds and large gatherings
- 1: Always
- 2: Often
- 3: Occasionally
- 4: Never
- 5: Not applicable
Health behaviour changes related to COVID-19 (HB) - Question identifier:HB_Q20F
Which of the following precautions is your family taking as protection against COVID-19?
Work from home when possible
- 1: Always
- 2: Often
- 3: Occasionally
- 4: Never
- 5: Not applicable
Health behaviour changes related to COVID-19 (HB) - Question identifier:HB_Q20G
Which of the following precautions is your family taking as protection against COVID-19?
Use delivery services or curbside pick-up
- 1: Always
- 2: Often
- 3: Occasionally
- 4: Never
- 5: Not applicable
Health behaviour changes related to COVID-19 (HB) - Question identifier:HB_Q20H
Which of the following precautions is your family taking as protection against COVID-19?
Limit contact with people at higher risk
- 1: Always
- 2: Often
- 3: Occasionally
- 4: Never
- 5: Not applicable
Health behaviour changes related to COVID-19 (HB) - Question identifier:HB_Q20I
Which of the following precautions is your family taking as protection against COVID-19?
Self-isolating as protection when concerned about exposure
- 1: Always
- 2: Often
- 3: Occasionally
- 4: Never
- 5: Not applicable
Health behaviour changes related to COVID-19 (HB) - Question identifier:HB_Q20J
Which of the following precautions is your family taking as protection against COVID-19?
Self-isolate to protect others after possible exposure to COVID-19
- 1: Always
- 2: Often
- 3: Occasionally
- 4: Never
- 5: Not applicable
Health assessment 1 (FLU)
Health assessment 1 (FLU) - Question identifier:FLU_Q05
In the past 12 months, has this child had a seasonal flu vaccine?
- 1: Yes
- 2: No
Health assessment 2 (HR)
Health assessment 2 (HR) - Question identifier:HR_Q10
When a COVID-19 vaccine becomes available to this child, how likely is it that you will choose to get one?
- 1: Very likely
- 2: Somewhat likely
- 3: Somewhat unlikely
- 4: Very unlikely
- 5: Already received a vaccine for COVID-19
Health assessment 2 (HR) - Question identifier:HR_Q15
What are the reasons this child would not get the COVID-19 vaccine?
- 01: Already had or think they have had COVID-19
- 02: Do not consider it necessary to get the vaccine
- 03: Not confident in the safety of the vaccine
- 04: Do not believe in vaccination
- 05: Concern about risks and side effects
- 06: Has a pre-existing medical condition
- 07: Will wait until it seems safe to get the vaccine
- 08: Have not yet decided
- 09: Other reason
- 99: DK
Health assessment 2 (HR) - Question identifier:HR_Q20
Does this child have a family physician or primary care provider?
- 1: Yes
- 2: No
- 9: DK
Health assessment 3 (GEN)
Health assessment 3 (GEN) - Question identifier:GEN_R01
The following question is about health. By health we mean not only the absence of disease or injury, but also physical, mental and social well being.
Health assessment 3 (GEN) - Question identifier:GEN_Q01
In general, how is this child's health?
Would you say:
- 1: Excellent
- 2: Very good
- 3: Good
- 4: Fair
- 5: Poor
Health assessment 4 (HWT)
Health assessment 4 (HWT) - Question identifier:HWT_Q05A
How tall is this child without shoes on?
Feet
Min = 0; Max = 9
Health assessment 4 (HWT) - Question identifier:HWT_Q05B
Inches
- 01: 0
- 02: 1
- 03: 2
- 04: 3
- 05: 4
- 06: 5
- 07: 6
- 08: 7
- 09: 8
- 10: 9
- 11: 10
- 12: 11
Health assessment 4 (HWT) - Question identifier:HWT_Q05C
Centimetres
Min = 0; Max = 999
Health assessment 4 (HWT) - Question identifier:HWT_Q40A
How much does this child weigh?
Weight
Min = 0; Max = 999
Health assessment 4 (HWT) - Question identifier:HWT_Q40B
Pounds or kilograms
- 1: Pounds
- 2: Kilograms
Demographic questions 1 (GDR)
Demographic questions 1 (GDR) - Question identifier:GDR_R05
The following questions are about sex at birth and gender.
Demographic questions 1 (GDR) - Question identifier:GDR_Q05
What was this child's sex at birth?
- 1: Male
- 2: Female
Demographic questions 1 (GDR) - Question identifier:GDR_Q10
What is this child's gender?
- 1: Male
- 2: Female
- 3: Or please specify
Demographic questions 1 (GDR) - Question identifier:GDR_Q15
Please verify that all of the information is correct.
Your information
Sex assigned at birth: #{__DT_SEX_E}
Gender: #{__DT_GDR_E}
Long Answer Length = 80
Demographic questions 3 (HHC)
Demographic questions 3 (HHC) - Question identifier:HHC_Q01
Including yourself, how many people live in your household?
Number of people
- 01: 1
- 02: 2
- 03: 3
- 04: 4
- 05: 5
- 06: 6
- 07: 7
- 08: 8
- 09: 9
- 10: 10
- 11: 11
- 12: 12
- 13: 13
- 14: 14
- 15: 15
- 16: 16
- 17: 17
- 18: 18
- 19: 19
- 20: 20 or more
Demographic questions 4 (DW)
Demographic questions 4 (DW) - Question identifier:DW_Q05
What type of dwelling is this?
Is it a:
- 01: Single detached
- 02: Double
- 03: Row or Terrace
- 04: Duplex
- 05: Low-rise apartment of fewer than 5 stories or a flat
- 06: High-rise apartment of 5 stories or more
- 07: Institution
- 08: Hotel, rooming or lodging house, camp
- 09: Mobile home
- 10: Other
Demographic questions 4 (DW) - Question identifier:DW_Q10
How many bathrooms are in this dwelling?
Number of bathrooms
Min = 0; Max = 9
Demographic questions 5 (DWL)
Demographic questions 5 (DWL) - Question identifier:DWL_Q04
How many bedrooms are in this dwelling?
Number of bedrooms
Min = 0; Max = 99
Demographic questions 6 (ED)
Demographic questions 6 (ED) - Question identifier:ED_Q05
What is the highest certificate, diploma, or degree that anyone in this household has completed?
- 1: Less than high school diploma or its equivalent
- 2: High school diploma or a high school equivalency certificate
- 3: Trades certificate or diploma
- 4: College, CEGEP or other non-university certificate or diploma (other than trades certificate or diplomas)
- 5: University certificate or diploma below the bachelor's level
- 6: Bachelor's degree (e.g., B.A., B.A. (Hons), B.Sc., B.Ed., LL.B.)
- 7: University certificate, diploma, or degree above the bachelor level
Indigenous identity (FN)
Indigenous identity (FN) - Question identifier:FN_Q01
Is this child First Nations, Métis or Inuk (Inuit)?
- 1: No, not First Nations, Métis or Inuk (Inuit)
- 2: Yes, First Nations (North American Indian)
- 3: Yes, Métis
- 4: Yes, Inuk (Inuit)
Sociodemographic characteristics 1 (PG)
Sociodemographic characteristics 1 (PG) - Question identifier:PG_Q05
The following question collects information in accordance with the Employment Equity Act and its Regulations and Guidelines to support programs that promote equal opportunity for everyone to share in the social, cultural, and economic life of Canada.
Is this child:
- 01: White
- 02: South Asian (e.g., East Indian, Pakistani, Sri Lankan)
- 03: Chinese
- 04: Black
- 05: Filipino
- 06: Arab
- 07: Latin American
- 08: Southeast Asian (e.g., Vietnamese, Cambodian, Laotian, Thai)
- 09: West Asian (e.g., Iranian, Afghan)
- 10: Korean
- 11: Japanese
- 12: Other
Sociodemographic characteristics 2 (FNS)
Sociodemographic characteristics 2 (FNS) - Question identifier:FNS_Q01
Is this child a Status Indian (Registered or Treaty Indian as defined by the Indian Act of Canada)?
- 1: No
- 2: Yes, Status Indian (Registered or Treaty)
Vaccination 1 (VX)
Vaccination 1 (VX) - Question identifier:VX_R05
The following questions are about vaccination against COVID-19.
Vaccination 1 (VX) - Question identifier:VX_Q05
Has this child been vaccinated against COVID-19?
- 1: Yes
- 2: No
Vaccination 1 (VX) - Question identifier:VX_Q10B
How many doses of the COVID-19 vaccine has this child received so far?
- 1: One dose
- 2: Two doses
- 3: More than two doses
Vaccination 1 (VX) - Question identifier:VX_Q15C
When did this child receive their first dose of the COVID-19 vaccine?
Day
- 01: 1
- 02: 2
- 03: 3
- 04: 4
- 05: 5
- 06: 6
- 07: 7
- 08: 8
- 09: 9
- 10: 10
- 11: 11
- 12: 12
- 13: 13
- 14: 14
- 15: 15
- 16: 16
- 17: 17
- 18: 18
- 19: 19
- 20: 20
- 21: 21
- 22: 22
- 23: 23
- 24: 24
- 25: 25
- 26: 26
- 27: 27
- 28: 28
- 29: 29
- 30: 30
- 31: 31
Vaccination 1 (VX) - Question identifier:VX_Q15B
Month
- 01: January
- 02: February
- 03: March
- 04: April
- 05: May
- 06: June
- 07: July
- 08: August
- 09: September
- 10: October
- 11: November
- 12: December
Vaccination 1 (VX) - Question identifier:VX_Q15A
Year
- 1: 2021
- 2: 2022
Vaccination 2 (DIR)
Vaccination 2 (DIR) - Question identifier:DIR_Q15A
Which vaccine did this child receive?
Was it:
- 1: Pfizer and BioNTech mRNA vaccine
- 2: Moderna mRNA vaccine
- 3: AstraZeneca Oxford vaccine
- 4: Other specify:
- 9: DK
Linking and sharing questions 1 (LNK)
Linking and sharing questions 1 (LNK) - Question identifier:LNK_R01
To enhance the data from this survey and to minimize the reporting burden for respondents, Statistics Canada will combine your responses with information from the tax data of all members of your household. Statistics Canada and the ministry of health for your home province or territory may also add information from other surveys or administrative sources.
For Quebec residents, the Institut de la statistique du Québec may add information from other surveys or administrative sources.
Linking and sharing questions 2 (HN)
Linking and sharing questions 2 (HN) - Question identifier:HN_R01
Having a provincial or territorial health number will assist Statistics Canada in linking the survey data to the provincial or territorial health information.
Linking and sharing questions 2 (HN) - Question identifier:HN_Q01
Does this child have a health card?
- 1: Yes
- 2: No
Linking and sharing questions 2 (HN) - Question identifier:HN_Q02
For which province or territory is the health card?
Health card province
- 10: Newfoundland and Labrador
- 11: Prince Edward Island
- 12: Nova Scotia
- 13: New Brunswick
- 24: Quebec
- 35: Ontario
- 46: Manitoba
- 47: Saskatchewan
- 48: Alberta
- 59: British Columbia
- 60: Yukon
- 61: Northwest Territories
- 62: Nunavut
Linking and sharing questions 2 (HN) - Question identifier:HN_Q03
What is this child's health card number?
Health card number
Long Answer Length = 12
Linking and sharing questions 3 (SHR)
Linking and sharing questions 3 (SHR) - Question identifier:SHR_R01
To avoid duplication of surveys, Statistics Canada may enter into agreements to share the data from this survey, including name, address, telephone number and health card number, with provincial and territorial ministries of health, Health Canada and the Public Health Agency of Canada. For Quebec residents, Statistics Canada may also enter into an agreement with the Institut de la statistique du Québec to share the same information.
The Institut de la statistique du Québec and provincial ministries of health may make this data available to local health authorities. Local health authorities will not receive any identifiers, only the postal code.
Linking and sharing questions 3 (SHR) - Question identifier:SHR_Q01
These organizations have agreed to keep the data confidential and use it only for statistical purposes.
Do you agree to share the data provided?
- 1: Yes
- 2: No
Linking and sharing questions 4 (TAX)
Linking and sharing questions 4 (TAX) - Question identifier:TAX_R01
To reduce the number of questions in this questionnaire, Statistics Canada will use information from your tax forms submitted to the Canada Revenue Agency. With your consent Statistics Canada will share this information from your tax forms with your provincial and territorial ministries of health, Health Canada and the Public Health Agency of Canada.
Quebec residents will also have their tax form information shared with the Institut de la statistique du Québec.
These organizations have agreed to keep the information confidential and to use it only for statistical and research purposes.
Linking and sharing questions 4 (TAX) - Question identifier:TAX_Q01
Do you give Statistics Canada permission to share your tax information?
- 1: Yes
- 2: No
COVID test procedure and consent (CON)
COVID test procedure and consent (CON) - Question identifier:CON_R01
You received a testing kit from Statistics Canada with the letter that invited you to complete this questionnaire. The purpose of the kit is to collect drops of blood by using the dried blood spot (finger prick) method at home. This child's blood will be used to determine if they have antibodies to the virus that causes COVID-19. To obtain accurate results, it is important to carefully follow the instructions provided in the kit.
COVID test procedure and consent (CON) - Question identifier:CON_Q50A
I understood the instructions provided in the kit and the risks associated with testing. I have also read and understood the steps taken for the secure storage of this child's blood sample. On this child's behalf, I am choosing to consent or not consent to the following:
Participating in the test
- 1: Yes
- 2: No
COVID test procedure and consent (CON) - Question identifier:CON_Q50B
I understood the instructions provided in the kit and the risks associated with testing. I have also read and understood the steps taken for the secure storage of this child's blood sample. On this child's behalf, I am choosing to consent or not consent to the following:
Receiving results
- 1: Yes
- 2: No
COVID test procedure and consent (CON) - Question identifier:CON_Q50C
I understood the instructions provided in the kit and the risks associated with testing. I have also read and understood the steps taken for the secure storage of this child's blood sample. On this child's behalf, I am choosing to consent or not consent to the following:
Storage of this child's blood for future health studies
- 1: Yes
- 2: No
COVID test procedure and consent (CON) - Question identifier:CON_R02
I understand that even though I have answered "Yes" to some or all of the items above, I can still withdraw from any part of this survey or subsequent studies at any time.
NOTE: If you would like more information before proceeding, please contact us by phone at 1-888-253-1087 or by email at statcan.ccahs-ecsac.statcan@canada.ca <mailto:statcan.ccahs-ecsac.statcan@canada.ca>.
Test and contact information 1 (TST)
Test and contact information 1 (TST) - Question identifier:TST_R01
Please perform the test as indicated in the instructions. If you would like more information before proceeding, please contact us by phone at 1-888-253-1087 or by email at statcan.ccahs-ecsac.statcan@canada.ca <mailto:statcan.ccahs-ecsac.statcan@canada.ca>.
Test and contact information 1 (TST) - Question identifier:TST_Q01
Has the test been completed?
- 1: Yes
- 2: No
Test and contact information 2 (NAD)
Test and contact information 2 (NAD) - Question identifier:NAD_Q01
In order for us to contact you about results or for future participation in the survey, please provide the following information:
Mailing address
Civic number
Min = 0; Max = 999999
Test and contact information 2 (NAD) - Question identifier:NAD_Q02
Civic number suffix
Long Answer Length = 3
Test and contact information 2 (NAD) - Question identifier:NAD_Q06
Apartment number
Long Answer Length = 6
Test and contact information 2 (NAD) - Question identifier:NAD_Q03
Street Name
Long Answer Length = 50
Test and contact information 2 (NAD) - Question identifier:NAD_Q04
Street type
- 1: List of street types
Test and contact information 2 (NAD) - Question identifier:NAD_Q05
Street direction
- 01: East
- 02: North
- 03: Northeast
- 04: Northwest
- 05: South
- 06: Southeast
- 07: Southwest
- 08: West
Test and contact information 2 (NAD) - Question identifier:NAD_Q13
Rural address
Long Answer Length = 60
Test and contact information 2 (NAD) - Question identifier:NAD_Q07
City, municipality, town, village, Indian reserve
Long Answer Length = 50
Test and contact information 2 (NAD) - Question identifier:NAD_Q10
Province or territory
- 10: Newfoundland and Labrador
- 11: Prince Edward Island
- 12: Nova Scotia
- 13: New Brunswick
- 24: Quebec
- 35: Ontario
- 46: Manitoba
- 47: Saskatchewan
- 48: Alberta
- 59: British Columbia
- 60: Yukon
- 61: Northwest Territories
- 62: Nunavut
Test and contact information 2 (NAD) - Question identifier:NAD_Q08
Postal code
Long Answer Length = 6
Test and contact information 3 (EA)
Test and contact information 3 (EA) - Question identifier:EA_Q01
Email address
Long Answer Length = 254
Test and contact information 4 (CEL)
Test and contact information 4 (CEL) - Question identifier:CEL_Q01
Telephone number
Long Answer Length = 12
Re-contact (FUP)
Re-contact (FUP) - Question identifier:FUP_Q01
We may want to contact your household to ask about your participation in a follow-up to this survey.
Do we have your permission to contact you?
- 1: Yes
- 2: No
- Date modified: