Attachments Z and AA - Emergency Response Surveys - Leve

Form Approved

OMB No. 0920-XXXX

Exp. Date xx/xx/20xx

Attachment Z: Emergency Response Survey (Professionals) (English)

Emergency Response Survey (Professionals) (English)

Items in [brackets] are instructions for the CSR—they are not read to the respondent. The CSR does NOT read the response options unless the instructions explicitly state that they are to do so—only the questions are read to the respondent.

1. What type of organization are you calling from?

1.	Medical Professional (doctor, nurse, medical librarian, medical association)
2.	Medical facility (hospital, clinic, HMO, long term care, institution [behavioral])
3.	Government (Federal, State, local, elected official)
4.	Health Department (State, local including county health clinic)
5.	International
6.	Law Enforcement/Early Responders (Police, fire, EMT)
7.	Military
8.	Veterinarian
9.	Education (schools, college, teacher, student, librarian, school nurse)
10.	Laboratory
11.	Law Firm (lawyers, professional corporation, ACLU)
12.	Organization/Association (not for profit, faith based, community based, environmental, health related [American Cancer Society])
13.	Business/Private Sector
14.	Correctional Facility
15.	Other (specify) ________________________
16.	Refused to answer

2. Are you calling about an individual or a facility?

1.	Facility
2.	Individual
3.	Refused to answer

If calling about a facility, skip to question 6.

3. Is this person considered to be part of a population at high risk?

1.	Yes
2.	No
3.	Refused to answer

Public reporting burden of this collection of information is estimated to average 5 minutes per response, including the time for reviewing instructions, searching existing data sources, gathering and maintaining the data needed, and completing and reviewing the collection of information. An agency may not conduct or sponsor, and a person is not required to respond to a collection of information unless it displays a currently valid OMB control number. Send comments regarding this burden estimate or any other aspect of this collection of information, including suggestions for reducing this burden to CDC/ATSDR Reports Clearance Officer; 1600 Clifton Road NE, MS D-74, Atlanta, Georgia 30333; ATTN: PRA (0920-XXXX)

4. Are you or the person you are calling about: [CSR reads the response options to indicating whether the caller is in a high risk category. Depending upon the emergency, response categories will differ. The categories below only represent examples

1.	Over 65 years old
2.	A Child under two years old
3.	Immune system compromised
4.	[Other, insert]
5.	N/A—population is not at risk
6.	Refused to answer

5. Has the person you are calling about been exposed?

1.	Yes
2.	No
3.	Not sure
4.	Refused to respond

6. How was the person you are calling about exposed?

1.	Breathing/Inhale Substance
2.	Touching/Contact with Skin
3.	Ingested
4	Bitten/Stung
5.	Injection/Needle stick
6.	Handled animal carcass
7.	Ate contaminated food
8.	Drank contaminated water
9.	[Other: write in]
10.	Refused to respond

7. Where was the person you are calling about exposed?

1.	Airport
2.	Correctional facility
3.	Government/Public building
4.	Home
5.	Industrial facility (factory, petrochemical plant, etc.)
6.	Laboratory
7.	Long-term care facility (nursing home, assisted living facility, etc.)
8.	Medical facility (hospital, clinic, HMO, institution [behavioral])
9.	Military base
10.	Outdoor facility (stadium, golf course, parks—including local, state and national)
11.	Private building (hotel, community based organization, etc.)
12.	Railroad
13.	School
14.	Shelter
15.	[Other: write in]
16.	Refused to respond

8. What kind of facility are you calling about?

1.	Airport
2.	Correctional facility
3.	Government/Public building
4.	Industrial facility (factory, petrochemical plant, etc.)
5.	Laboratory
6.	Long-term care facility (nursing home, assisted living facility, etc.)
7.	Medical facility (hospital, clinic, HMO, institution [behavioral])
8.	Military base
9.	Outdoor facility (stadium, golf course, parks—including local, state and national)
10.	Private building (hotel, community based organization, etc.)
11.	Railroad
12.	School
13.	Shelter
14.	[Other: write in]
15.	Refused to answer

8. Where is affected area/where are the affected people? (e.g. city, county, parish, borough, ward).

8. What is the zip code?

11. How many people are affected?

12. May I have your name and contact information, please? [Include cell phone and e-mail address, as well as land line]

13. Where are you getting information about this event? [Choose all that apply]

1.	Internet
2.	Newspaper
3.	Public Health Department
4.	Radio
5.	T.V. news
6.	[Other: write in]
7.	Refused to respond

13. Has the information that you have received so far been easy to understand?

1.	Yes
2.	No
3.	Refused to respond

13. What information do you still need?

16. [If calling about an individual] How would you describe the person you are calling about? Is she/he: [CSR reads the response options]

1.	Hispanic or Latino
2.	Black or African American
3.	White
4.	Asian
5.	American Indian or Alaska Native
6.	Native Hawaiian or Other Pacific Islander
7.	Refused to respond

17. [If calling about an individual] How old is the person you are calling about?

1.	1 year old or less
2.	2-3 years old
3.	4-5 years old
4.	6-7 years old
5.	8-9 years old
6.	10-11 years old
7.	12-13 years old
8.	14-15 years old
9.	16-17 years old
10.	18-19 years old
11.	20-34 years old
12.	35-49 years old
13.	50-64 years old
14.	65 or older
15.	Refused to respond

Those are all of the questions. Thank you for calling CDC-INFO. Goodbye.

Attachment AA: Emergency Response Survey (Professionals) (Spanish)

Emergency Response Survey (Professionals) (Spanish)

Items in [brackets] are instructions for the CSR—they are not read to the respondent. The CSR does NOT read the response options unless the instructions explicitly state that they are to do so—only the questions are read to the respondent.

1. ¿De qué tipo de organización esta llamando?

1.	Medical Professional (doctor, nurse, medical librarian, medical association)
2.	Medical facility (hospital, clinic, HMO, long term care, institution [behavioral])
3.	Government (Federal, State, local, elected official)
4.	Health Department (State, local including county health clinic)
5.	International
6.	Law Enforcement/Early Responders (Police, fire, EMT)
7.	Military
8.	Veterinarian
9.	Education (schools, college, teacher, student, librarian, school nurse)
10.	Laboratory
11.	Law Firm (lawyers, professional corporation, ACLU)
12.	Organization/Association (not for profit, faith based, community based, environmental, health related [American Cancer Society])
13.	Business/Private Sector
14.	Correctional Facility
15.	Other (specify) ________________________
16.	Refused to answer

2. ¿Está usted llamando acerca de una persona o una instalación?

1.	Facility
2.	Individual
3.	Refused to answer

If calling about a facility, skip to question 6.

3. ¿Está la persona considerada como parte de una población de/en alto riesgo?

1.	Yes
2.	No
3.	Refused to answer

De acuerdo a gravámenes en informes públicos el promedio para recaudar ésta información es de 3 minutos por respuesta, lo cual incluye el tiempo utilizado para revisar instrucciones, buscar fuentes de datos ya existentes, recaudar y conservar datos necesarios, y completar y analizar la recaudación de la información. Una recaudación de información no debe llevarse a cabo o ser auspiciada por una agencia al menos que dicha recaudación lleve consigo un número actual de control OMB válido. De igual modo una persona no debe responder una recaudación de información si dicha recaudación no presenta un número actual de control OMB válido. Por favor sírvase enviar comentarios con respecto al estimado de este gravamen o de cualquier otro aspecto de ésta recaudación de información, también se pueden incluir sugerencias en cómo reducir este gravamen a CDC/ATSDR Reports Clearance Officer, 1600 Clifton Road NE, MS D-74 Atlanta, Georgia 30333. ATTN: PRA (0920-XXXX)

4. ¿Es usted o la persona para la cual llamó: [CSR reads the response options to indicating whether the caller is in a high risk category. Depending upon the emergency, response categories will differ. The categories below only represent examples

1.	Es usted mayor de 65 años de edad
2.	Es la persona para la cual llamo un niño menor de dos años de edad
3.	Tiene usted o la persona un sistema inmunológico comprometido (en riesgo)
4.	[Other, insert]
5.	N/A—población no en riesgo
6.	Rehusa a responder

5. ¿Ha estado expuesta la persona para la cual llamó?

1.	Yes
2.	No
3.	Not sure
4.	Refused to respond

6.¿Cómo estuvo expuesta la persona para la cual llamó?

1.	Breathing/Inhale Substance
2.	Touching/Contact with Skin
3.	Ingested
4	Bitten/Stung
5.	Injection/Needle stick
6.	Handled animal carcass
7.	Ate contaminated food
8.	Drank contaminated water
9.	Vaccination
10.	[Other: write in]
11.	Refused to respond

7. ¿Dónde estuvo expuesta la persona para la cual llamó?

1.	Airport
2.	Correctional facility
3.	Government/Public building
4.	Home
5.	Industrial facility (factory, petrochemical plant, etc.)
6.	Laboratory
7.	Long-term care facility (nursing home, assisted living facility, etc.)
8.	Medical facility (hospital, clinic, HMO, institution [behavioral])
9.	Military base
10.	Outdoor facility (stadium, golf course, parks—including local, state and national)
11.	Private building (hotel, community based organization, etc.)
12.	Railroad
13.	School
14.	Shelter
15.	[Other: write in]
16.	Refused to respond

8. ¿Acerca de qué tipo de instalación esta usted llamando?

1.	Airport
2.	Correctional facility
3.	Government/Public building
4.	Industrial facility (factory, petrochemical plant, etc.)
5.	Laboratory
6.	Long-term care facility (nursing home, assisted living facility, etc.)
7.	Medical facility (hospital, clinic, HMO, institution [behavioral])
8.	Military base
9.	Outdoor facility (stadium, golf course, parks—including local, state and national)
10.	Private building (hotel, community based organization, etc.)
11.	Railroad
12.	School
13.	Shelter
14.	[Other: write in]
15.	Refused to answer

9. ¿Dónde se encuentra el área afectada/En dónde se encuentran la personas afectadas? (e.j. ciudad, condado, parroquia, municipio, sala de hospital).

10. ¿Cuál es su código postal?

11. ¿Cuántas personas estan afectadas?

12. Me podría dar su nombre y su datos personales como dirección, teléfono, etc? [Include cell phone and e-mail address, as well as land line]

13. ¿Dónde esta obteniendo la información acerca de este evento? [Choose all that apply]

1.	Internet
2.	Newspaper
3.	Public Health Department
4.	Radio
5.	T.V. news
6.	[Other: write in]
7.	Refused to respond

14. ¿Ha sido fácil de entender la información que ha recibido hasta ahora

1.	Yes
2.	No
3.	Refused to respond

15. ¿Hay alguna otra información qué necesite?

16. [If calling about an individual] ¿Cómo se describe la persona para la cual llamó? [CSR reads the response options]

1.	Hispano o Latino
2.	Negro o Afro-americano
3.	Blanco
4.	Asiático
5.	Indio-Americano o Nativo de Alaska
6.	Nativo Hawaiano u Otro isleño del Pacífico
7.	Rehusa a responder

17. [If calling about an individual] ¿Cuántos años tiene la persona para la cual llamó?

1.	1 year old or less
2.	2-3 years old
3.	4-5 years old
4.	6-7 years old
5.	8-9 years old
6.	10-11 years old
7.	12-13 years old
8.	14-15 years old
9.	16-17 years old
10.	18-19 years old
11.	20-34 years old
12.	35-49 years old
13.	50-64 years old
14.	65 or older
15.	Refused to respond

Those are all of the questions. Thank you for calling CDC-INFO. Goodbye.