FEMA Nuclear Power Plant Alerting And Notification System: Public Telephone Survey

O.M.B. No. 1660-

Expires,

FEMA Form 111

PAPERWORK BURDEN DISCLOSURE NOTICE

Public reporting burden for this form is estimated to average 10 minutes hour per response. The burden estimate includes the time for reviewing instructions, searching existing data sources, gathering and maintaining the data needed, and completing and submitting the form. You are not required to respond to this collection of information unless it displays a valid OMB control number.  Send comments regarding the accuracy of the burden estimate and any suggestions for reducing the burden to: Information Collections Management, Department of Homeland Security, Federal Emergency Management Agency, 500 C Street, SW, Washington, DC 20472, Paperwork Reduction Project (1660-0054) NOTE: Do not send your completed form to this address.

Cabezon Group Inc.

8850 Columbia 100 Parkway, Suite 314

Columbia, MD 20145-2377

Radiological Emergency Preparedness Program Alert and Notification Phone Survey

Time Began ________AM _________PM Interview #______________

(1-5)

Time Ended ________AM _________PM Zip Code ______________

(6-10)

Record before Dialing – Telephone # ________________________________________

(Area code) (Exchange) (Number) (12-21)

Respondent: Male or Female Head of Household

(Ask: are you the head of the household?)

Introduction:

1. Hello my name is ________________________. We are calling households long distance from Cabezon Group Inc. as part of a survey. This survey is sponsored by the Federal Emergency Agency (FEMA) of the United States Government. Your answers are voluntary and will be kept strictly confidential.
   
   First of all, is this (Repeat # dialed)?

	Yes	1
Terminate and Dial Again	No	2

2. As you may not know, there was a test of the emergency alert notification system for _______________________________ (Name of Power Plant). Did you or any other member of your household hear or see any type of emergency signal from this test today?

Continue	Yes	1
Skip to Question 4A	No	2
Continue	Heard from another source	3
Ask if another household member has any more knowledge of the test	Don’t know	8

(22)

3. How were you made aware of this emergency test signal? (Do not read the following – circle all answers that pertain to the information given by the household member.)

	Siren (probe for type)
	Fixed Siren	1
	Mobile Siren	2
	Don’t know	3
	Tone Alert Radio	4
	Neighbor told me	5
	Other family member told me	6
Specify	Other:	7
Continue	Don’t know	Y
Skip to Q 4.

(23-29)

3A. Were you made aware by a (read the following list – Circle all that apply)

	Fixed Siren	1
	Mobile Siren	2
	Tone Alert	4
	Neighbor	5
	Another Family Member	6
Specify	Other	7
Do Not Read	Siren – Don’t know type	3
Do Not Read	Don’t know	Y

(30-36)

4. (If they heard or saw a signal – ask Q 4. below Otherwise skip to Q 4A.)

Were you at home or away from home when you were made aware of this emergency test signal?

(Skip to Q 5. Unless this is a Tone Alert Area and respondent did not answer Siren or Tone alert in Q 3. or Q 3A. Otherwise skip to Q 4B.)

	Home	1
	Away from home	2

(37)

4A. (If you did not hear or see emergency signal)

Were you inside your house at the time of the alert signal today?

(If Tone Alert Area ask Q 4B. otherwise skip to Q 5.)	Yes	1
Skip to Q 5.	No	2
Skip to Q 5.	Don’t know	Y

(38)

4B. Has your household ever been issued a Tone Alert Radio?

	Yes	1
Skip to Q 5.	No	2
Skip to Q 5.	Don’t Know	Y

(39)

4C. Was it turned on and in the Alert Mode at the time of the test today?

	Yes	1
	No	2
	Don’t know	Y

(40)

5. Has your household ever received a description of the instruction which tell you what to do in a real emergency at _________________________ (Name of reactor)?

	Yes	1
	No	2
	Don’t know	Y

(41)

6. Because we need to determine whether or not you live in the Emergency Planning Zone (EPZ) of _____________________ (Name of reactor), would you please give me your address?

Address:______________________________________________________________________________________________________________________________________________________________________________________________

And the nearest cross street or main road to your home: _______________________________________________________________________________________________________________________________

On behalf of the Cabezon Group Inc and the Federal Emergency Management Agency, I would like to thank you for taking the time to help us obtain this valuable information.