CDEs
Forms
Getting to where I need to go
Do you speak a language other than English at home?
What language(s)
Specify other language(s)
In 2019, what was your total household income before taxes?
Date of Work PPE and Distancing Collection
In your workplace, do you have access to necessary facilities to wash?
Does your work require you to be in close contact (i.e. within 6 ft) with others?
In your workplace, do you have access to necessary personal protective equipment (PPE)?
Date of Medical History Collection
Immunocompromised condition
Autoimmune disease
Hypertension (HTN, high blood pressure)
Diabetes
Chronic kidney disease (CKD)
Cancer diagnosis and/or treatment within the past 12 months
Cardiovascular disease (CVD or heart disease)
Asthma
Chronic obstructive pulmonary disease (COPD)
Other chronic lung disease
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