SURVEY – QUESTIONNAIRE OF COVID 19’S EFFECTS TO MY

FAMILY MEMBERS
I am carrying out an evaluation of the effects of Covid-19 to the lives of my family
members, to see if they have recover and make use the effects of Covid-19 to their
advantage. Thank you for taking the time to fill in this questionnaire; it should only
take 10 minutes. Your answers will be treated with complete confidentiality.

Section A (Before the spread of Covid-19)

1. Before the spread of Covid-19, how many times do you go out to buy some
things? : (please tick one)

less than once a month 

once a month 
once every two weeks 
once a week 
two or three times a week 
daily 

2. What things have you bought based on question no.1? (please tick all that apply)

Tissue 
Alcohol/sanitizer 
Face masks 
Face shield 
Vegetables 
Fruits 
Clothes 
other (please state: ___________________) 

3. Before the spread of Covid-19, how often do you spend your time with your
family? (please tick one).

less than once a month 

once a month 
once every two weeks 
once a week 
two or three times a week 
daily 

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4. Before the spread of Covid-19, how many times do you work overtime? (please
tick one)

less than once a month 

once a month 
once every two weeks 
once a week 
two or three times a week 
daily

5. Before the spread of Covid-19, what hobbies do you have?(please tick all that
apply)

Yoga 
Exercise 
Meditation 
Gardening 
Reading (books, magazines, newspapers, etc.) 
Other(please state:________________) 
None 

6. Do you have already an existing mental health issue/s even before the spread of
Covid-19? (please tick one)

Yes 
No 

If yes, please go to question 7.

If no, please continue with question 8.

7. What mental health issue/s do you have?(please tick all that apply)

Depression 
Anxiety 
cybercafé 
work 
other (please say where) 
8. What things do you do to avoid having mental health issue/s?

Yoga 
Exercise 
Meditation 
Gardening 
Reading (books, magazines, newspapers, etc.) 
Other(please state:________________) 
None 
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Section B. (During the spread of Covid-19)

9. Did you developed mental health issue/s as the Covid-19 became rampant?
(please tick one)

Yes 
No 

If yes, please go to question 10.

If no, please continue with question 8.

10. What mental health issue/s do you have?(please tick all that apply)

Depression 
Anxiety 
cybercafé 
work 
other (please say where) 
11. What things do you do to avoid having mental health issue/s?

Yoga 
Exercise 
Meditation 
Gardening 
Reading (books, magazines, newspapers, etc.) 
Other(please state:________________) 
None 

12. During the spread of Covid-19, how often do you spend your time with your
family? (please tick one).

less than once a month 

once a month 
once every two weeks 
once a week 
two or three times a week 
daily 

3
13. During the spread of Covid-19, how many times do you work overtime? (please
tick one)

less than once a month 

once a month 
once every two weeks 
once a week 
two or three times a week 
daily

14. During the spread of Covid-19, how many times do you go out to buy some
things? : (please tick one)

less than once a month 

once a month 
once every two weeks 
once a week 
two or three times a week 
daily 

15. What things have you bought based on question no. 11? (please tick all that
apply)

Tissue 
Alcohol/sanitizer 
Face masks 
Face shield 
Vegetables 
Fruits 
Clothes 
other (please state: ___________________) 

16. During the spread of Covid-19, what hobbies do you have?(please tick all that
apply)

Yoga 
Exercise 
Meditation 
Gardening 
Reading (books, magazines, newspapers, etc.) 
Other(please state:________________) 
None 

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Section C.

17. Are you:

male 
female 

18. Are you:

full-time employed 
part-time employed 
self-employed 
not in paid employment 
student 
working student 
retired 
other (please state:__________) 

19. Are you:

under 16 
16-25 
26-35 
36-45 
46-55 
56-65 
over 65 

20. Do you consider yourself to have a disability?

No 
Yes 
(please specify:_______________)

Thank you very much for taking the time to complete this questionnaire.
Please hand it back to me, or put it in the box provided.
If you have any other comments, please add them below:

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10. Are you:

full-time employed
part-time employed
self-employed
unemployed
student
student and working
retired
other (please say what)

11. How would you describe your ethnic background?

White
Black Caribbean
Black African
Black Other
Indian
Pakistani
Bangladeshi
Chinese
Other (please say what)

12. Do you consider yourself to have a disability?

Yes
No

13. Are you a resident of [insert local authority area]?

Yes
If yes, please ask for their postcode.

No
If no, are you visiting from:
within the UK
outside the UK

Ask them if they have any other comments, and if they do, note them below:

Thank them for taking the time to answer the questionnaire.