Attachments X and Y - Emergency Response Surveys - Level

Form Approved

OMB No. 0920-XXXX

Exp. Date xx/xx/20xx

Attachment X: Emergency Response Survey (General Public) (English)

Emergency Response Survey (General Public) (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. Who are you calling for?

1.	Self
2.	Child
3.	Wife/Husband
4.	Parent/Grandparent
5.	Other Relative
6.	Partner
7.	Neighbor
8.	Other
9.	Refused to respond

2. 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

3. Have you been exposed? [OR] Has the person you are calling about been exposed?

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

Public reporting burden of this collection of information is estimated to average of 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. How were you exposed? [OR] 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.	Vaccination
10.	[Other: write in]
11.	Refused to respond

5. Where were you exposed? [OR] 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

6. What is your zip code?

7. How old are you? [OR ] 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

8. Are you male or female? [OR] Is the person you are calling about male or female?

1.	Male
2.	Female
3.	Refused to respond

9. How would you describe yourself? Are you: [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

9. 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

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

1.	Yes
2.	No
3.	Refused to respond

9. What information do you still need?

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

Attachment Y: Emergency Response Survey (General Public) (Spanish)

Emergency Response Survey (General Public) (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. Para quién esta llamando?

1.	Self
2.	Child
3.	Wife/Husband
4.	Parent/Grandparent
5.	Other Relative
6.	Partner
7.	Neighbor
8.	Other
9.	Refused to respond

2. 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

3. ¿Ha estado expuesto? [OR] ¿Ha estado la persona para la cual llamó expuesta?

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

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. ¿Cómo estuvo expuesto? [OR] 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.	[Other: write in]
10.	Refused to respond

5. ¿Dónde estuvo expuesto? [OR] ¿Dónde estuvo expuesta la persona para la cuál 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

6. ¿Cuál es su código postal?

7. ¿Cuántos años tiene? [OR ] ¿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

8. ¿Es usted hombre o mujer? [OR] ¿Es la persona para la cual llamó hombre o mujer?

1.	Male
2.	Female
3.	Refused to respond

9. ¿Cómo se describe a si mismo? Es usted: [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

10. ¿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

11. ¿Ha sido fácil (de) entender la información que ha recibido hasta ahora?

1.	Yes
2.	No
3.	Refused to respond

12.¿Hay alguna otra información qué necesite aún?

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