Format (Use either “PDF” or “Text” [MS Word]. If the format is different from the two options listed, then select N/A.) PDF TEXT N/A Description (Provide a short summary description of the tool. Information to provide, if available, may include date of creation, when, where and how the tool has been used, unit of analysis [individual, household, worksite, etc.], domestic or international use, special populations, validation, and any other relevant information. For an example of a well-resourced description, see the University of Miami's IPHCPS record in DR2.) Questions Adapted From (If your questionnaire is taken from other sources, please list questions and source of question [ex. Q1-Q4 is taken from CDC CDE, Demographics module is taken from NHANES, etc.].) Population (Select All That Apply by clicking in the box below) Adult Workers Adults and Teens Adults Only All/Anyone Children/Teens Only Cleanup/Disaster Worker Ethnic/Religious Groups Evacuees/Refugees First Responders, Emergency Medical Services (EMS) Personnel, Police/Fire Departments High Risk/Special/Unique Populations Military Multiple Groups Other Pregnant or Lactating Women Residential/Workplace Sexual or Gender Minorities Mode of Administration (Select All That Apply by clicking in the box below) Face-to-face Online (e.g., computer-assisted interview) Pen and Paper Telephone Administered By (Select All That Apply by clicking in the box below) Lay Interviewer Parent/Teacher Professional Interviewer Self Administered Specialist/Doctor/Expert Trained Lay Examiner/Interviewer Special Considerations for Administration (Take note of any special considerations for administration. For example, the following note was provided for the Hamilton Depression Rating Scale [HAM-D]: “While the original scale required a trained clinician to administer the interview, structured and semi-structured interview-versions now exist so the HAM-D can be administered by interviewers without backgrounds in psychiatry.”) COVID-19 Main Topics (Select topics that correspond with sections of your tool. Select All That Apply by clicking in the box below. To be completed when submitting COVID-19 tools only.) Community Impacts Comorbidities Demographics Diagnosis, Status, Treatment, Recovery Environmental Factors Government Support Mental Health Other Perceptions Personal and Family Impacts Risk-Reduction Behaviors Symptoms Travel History URL (Provide tool URLs, if available. If no URL is available, please upload tool documents. Enter multiple URLs [separated by comma] for multiple modules or one URL for full survey. If other study materials are available such as biospecimens/sample collection protocols or instructions, manuals of procedures, IRB research protocol, data dictionary etc., please enter URLs here.) Availability (Most tools in the DR2 repository are free and publicly available. However, if there are costs or any special permissions are required prior to the use of tool, please indicate here.) Select One Free/Publicly Available Permission/Request required Proprietary - Cost/Purchase required Proprietary - Training Required Citations (Provide citation if available.) Are you submitting this for: Your Self? The Tool Developer?