Form FEMA Form 008-0-15 FEMA Form 008-0-15 Community Preparedness and Participation Survey

OMB No. 1660-0105

Expiration Date:  July 31, 2013

PAPERWOR REDUCTION ACT

BURDEN DISCLOSURE NOTICE

FEMA Form 008-0-15

Public reporting burden for this survey is estimated to average 30 15 minutes 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 survey. This collection of information is required to voluntary. You are not required to respond to this collection of information unless it displays a valid OMB control number is displayed in the upper right corner of this form.  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, 1800 South Bell Street, Arlington VA 20598-3005, Paperwork Reduction Project (1660-0105) NOTE: Do not send your completed form to this address.

Citizen Corps Household Survey Instrument

FEMA National Survey Instrument

INTRODUCTION

Hello, my name is ____________ and I am calling from Research Company. We are conducting public opinion research under contract with the Federal Emergency Management Agency (FEMA). For this research, we are obtaining people’s views about how well prepared they are for an emergency or disaster in their communities.

S1a. Is this a private residence?

1. YES

2. NO

(S1a_02) Thank you very much, but we are only interviewing private residences. Thank you for your time.

S2. I would like to speak with an adult, age 18 or older, who lives in the household. Would that be you?

1. YES Continue

2. NO Ask to transfer to adult

99 REFUSED End Interview

NewS2. May I speak with an adult member of the household?

1. YES, transferring

2. NOT AVAILABLE Schedule callback

99 REFUSED End Interview

S3. Hello, my name is ____________ and I am calling from Research Company. We are conducting public opinion research under contract with the Federal Emergency Management Agency (FEMA). For this research, we are obtaining people’s views about how well prepared they are for an emergency or disaster in their communities.

1. CONTINUE

99 REFUSED End Interview

Cell Phone Screener

QNS1

QID:172048 Have I reached you on a landline phone or on a cell phone?

(Interviewer: If respondent says ‘home phone,’ ‘VOIP/Internet phone,’ or any type of phone other than a cell phone, code as ‘1.’)

1	Landline
2	Cell Phone
3	(DK)
4	(Refused)
5	(Business Line-Landline or Cell) [VOLUNTEERED]

QNSC2

QID:172055 For your safety, are you currently driving?

1	Yes
2	No
3	(DK)
4	(Refused)

Thank you very much for your time. End Interview

Intro2a. The survey will only take about 15 minutes.

Your telephone number was chosen randomly. I will not ask for your name, address, or other personal information that can identify you. You do not have to answer any question you do not want to, and you can end the interview at any time. Your participation in this survey is entirely voluntary. Your answers to the survey questions will be held confidential by Research Company. Your name or any other information that could identify you will not be associated with your responses or used in any reports. If you have any questions, I will provide a telephone number—either here at Research Company or FEMA—for you to call to get more information or to validate this research.

This interview may be monitored or recorded for quality assurance purposes.

1. CONTINUE

2. RESPONDENT WANTS MORE INFORMATION

99 REFUSED END INTERVIEW

Contact details were provided to respondent wanting more information about the survey.

Section A.

Including yourself, how many adults, 18 years of age or older, live in this household?

01	01
96	96
97	97 or more
98	(DK)
99	(Refused)

A2. Are thereHow many children, under the age of 18, are living in your residence?household?

01

01	01-
96	96
97	97 or more
98	(DK)
99	(Refused)

YES

02 NO

97 DON’T KNOW

99 REFUSED

Ask those with children under the age of 18 living in the residence.

A3. Does at least one of the children currently attend a school outside of your home, including day care or part-time kindergarten?

1. YES

2. NO

97. DON’T KNOW

99 REFUSED

A4. Which best describes your job status?

[INTERVIEWER: READ LIST, CHOOSE UP TO TWO RESPONSES]

01 Work full-time

02 Work part-time

03 Student

04 Unemployed

05 Retired

95 Other

97 DON’T KNOW

99 REFUSED

I’d like to ask you some questions about different kinds of disasters. Throughout this survey, when I use the term “disaster”, I am referring to events that could disrupt public services, threaten lives, or damage property.

Throughout this survey, when I use the term “disaster”, I am referring to events that could disrupt public services, threaten lives, or damage property.

Do individuals think they are at risk for a disaster? (Perceived Risk)

All areas of the country are subject to different types of disasters - will you please name the types of disaster that would have the biggest impact where you live?

(Interviewer: Open ended and code)

(Programmer: Allow up to three responses)

01	Other (list)
02	(DK)
03	(Refused)
04	None
05	All
06	An earthquake
07	A tornado
08	A hurricane
09	A major snowstorm
10	A wildfire
11	A flood
12	Extreme heat
13	Storm surge
14	Nuclear event
15	Volcano
16	Tsunami
17	Radiological release
18	Terrorist attack
19	Land slide

On a scale of 1 to 5, with 5 being “very likely” and 1 being “not likely at all,” how likely do you think…?

C1. Some type of natural disaster will ever occur in your community?

05 VERY LIKELY

04

03

02

01 NOT LIKELY AT ALL

97 DON’T KNOW

99 REFUSED

C2. Some type of terrorism will ever occur in your community?

C3. Some type of hazardous materials accident will ever occur in your community?

C4. Some type of disease outbreak will ever occur in your community?

Do individuals think there will be a severe impact? (Perceived Severity)

D1. On a scale of 1 to 5, with 5 being “very severe” and 1 being “not severe at all,” how severe do you think the impact would be to you for….?

Items A – D, below, should be randomized

1. A natural disaster, such as an earthquake, a hurricane, a flood, a tornado, or wildfires

05 VERY LIKELY

04

03

02

01 NOT LIKELY AT ALL

97 DON’T KNOW

99 REFUSED

2. An act of terrorism, such as biological , chemical, radiological, or explosive attack

3. A hazardous materials accident, such as a transportation accident or a power plant accident

4. A highly contagious disease outbreak, such as a H1N1 flu epidemic

Using a five-point scale, where a 1 is strongly disagree and a 5 is strongly agree, to what extent do you agree or disagree with the following statement:

If I see an issue or concern in my community, it is my responsibility to work to fix it.

1	Strongly disagree
2
3
4
5	Strongly agree
8	(DK)
9	(Refused)

How Confident Are Individuals In Their Abilities to Respond to Different Disasters? (Ability to Respond/Response Self Efficacy)

G1. How confident are you in your ability to know what to do [fill in from below]? Please use a scale of 1 to 5, with 5 being “very confident” and 1 being “not at all confident.”

Items a-g, below, should be randomized

In the first five minutes of a terrorist act such as an explosion of a radiological or dirty bomb?

In the first five minutes of a hazardous materials accident such as the release of a chemical agent?

c. In the first five minutes of a sudden natural disaster such as an earthquake or tornado that occurs without warning?

In a highly contagious disease outbreak such as H1N1?

In a weather emergency such as a hurricane or major snowstorm?

In a wildfire?

In a flood?’

05 VERY CONFIDENT

04

03

02

01 NOT AT ALL CONFIDENT

97 DON’T KNOW

99 REFUSED

G1.A. How confident are you that you can take the steps to prepare for __________? Would you say you are (read 1-5)?

(Interviewer: read and rotate C2A-C2E)

1	Not at all confident
2	Slightly confident
3	Somewhat confident
4	Moderately confident
5	Extremely confident
8	(DK)
9	(Refused)

C2A	QID:229119	An earthquake	C2A(2211)
C2B	QID:229122	A tornado	C2B(2212)
C2C	QID:229123	A hurricane	C2C(2213)
C2D	QID:229120	A flood	C2D(2214)
C2E	QID:229121	Extreme heat	C2E(2215)
C2F		A chemical release
C2G		Winter weather
C2H		A pandemic

Do People Think Preparing in Advance Will Make a Difference in Their Ability to Respond to a Disaster? (Preparedness Helps/Response Efficacy)

G2. How much do you think preparing for a [fill in from below] will make a difference in how you handle the situation? By handle the situation I mean: know what to do, have supplies on hand and have a plan in place? Please use a scale of 1 to 5, 5 being “very much” and 1 being “not much at all.”

Items a-g, below, should be randomized

1. A terrorist act such as an explosion of a radiological or dirty bomb?

2. A hazardous materials accident such as the release of a chemical agent?

3. A highly contagious disease outbreak such as h1n1 flu?

4. A natural disaster?

5. A weather emergency such as a hurricane or major snowstorm?

6. A wildfire?

7. A flood?

05 VERY MUCH

04

03

02

01 NOT MUCH AT ALL

97 DON’T KNOW

99 REFUSED

G2.A. How much would taking steps to prepare, such as creating a household emergency plan or signing up for alerts and warning systems, help you get through __________? (Read 1-5)

(Interviewer: read and rotate C1A-C1E)

1	Not at all
2	Very little
3	Somewhat
4	Quite a bit
5	A great deal
8	(DK)
9	(Refused)

C1A	QID:229112	An earthquake	C1A(2201)
C1B	QID:229113	A tornado	C1B(2202)
C1C	QID:229114	A hurricane	C1C(2203)
C1D	QID:229115	A flood	C1D(2204)
C1E	QID:229116	Extreme heat	C1E(2205)
C1F		A chemical release
C1G		Winter weather
C1H		A pandemic

Stages of Change

E2. In thinking about preparing yourself for a major disaster, which best represents your preparedness?

[INTERVIEWER: READ ENTIRE LIST, CHECK ONLY ONE RESPONSE]

01 I have not yet prepared but I intend to in the next 6 months

02 I have not yet prepared but I intend to in the next month

03 I just recently began preparing

04 I have been prepared for at least the past 6 months

05 I am not planning to do anything about preparing

97 DON’T KNOW

99 REFUSED

Reliance and Responsibility Following a Disaster

F1. In the first 72 hours following a disaster, please indicate how much you would expect to rely on the following for assistance. Please use a scale of 1 to 5, with 5 being “expect to rely on a great deal” and 1 being “do not expect to rely on at all.”

Items a-f, below, should be randomized

1. Household members

2. People in my neighborhood

3. Non-profit organizations, such as the American Red Cross or the Salvation Army

4. My faith community, such as a congregation

5. Fire, police, emergency personnel

6. State and Federal Government agencies, including FEMA

05 EXPECT TO RELY ON A GREAT DEAL

04

03

02

01 DO NOT EXPECT TO RELY ON AT ALL

97 DON’T KNOW

99 REFUSED

Be Informed: Preparedness Training

G3. In the past 2 years, have you done any of the following? Have you…

Items a-f, below, should be randomized

a. Attended a meeting on how to be better prepared for a disaster

b. Attended CPR training

c. Attended first aid skills training

d. Attended training as part of a Community Emergency Response Team or CERT

e. Talked about getting prepared with others in your community

f. Aside from a fire drill, participated in a preparedness exercise or drill like the GreatShakeOut at your workplace, school, or home

01 YES

02 NO

97 DON’T KNOW

99 REFUSED

G4. Please indicate how recently you, personally, have taken any of the following actions to prepare for a possible disaster. How recently have you (read and rotate B2A-B2C), has it been (read 1-3)?

1	Within the past six months
2	More than six months but less than a year ago, or
3	More than a year ago
4	(I have not done this)
8	(DK)
9	(Refused)

B2A	QID:229086	Attended a meeting or training on preparedness about your local disasters	B2A(2141)
B2B	QID:229088	Talked with others in your community about getting prepared for a disaster	B2B(2142)
B2C	QID:229087	Sought information about preparedness	B2C(2143)

Build a Kit: Disaster Supplies

For this next set of questions, I’d like to ask you about some specific things you may or may not have done to prepare yourself and/or your household.

I1. Do you have supplies set aside in your home to be used only in the case of a disaster?

01 YES

02 NO

97 DON’T KNOW

99 REFUSED

Ask if the respondent has supplies set aside in the home to be used in the case of a disaster

I2. Could you tell me the disaster supplies you have in your home?

[DO NOT READ LIST]

[PROBE: Anything else?. Record all responses]

01-A SUPPLY OF BOTTLED WATER

02-A SUPPLY OF PACKAGED FOOD

03-A FLASHLIGHT

04-A PORTABLE, BATTERY-POWERED RADIO

05-BATTERIES

06-A first AID KIT

07-EYEGLASSES

08-MEDICATIONS

HOTOcopies OF PERSONAL identification

10-FINANCIAL DOCUMENTS

11-CASH

12-Blankets/Clothing/Bedding

13-Generator/Electrical Backup/Alternative Power

14-Candles/Matches

15-Stove/Lantern/Lamps

16-Fuel (Includes Gas,Propane,Firewood,Kerosene,Cooking Fuel)

17-Camping Gear/Tents/Sleeping Bags

18-Guns,Ammo,Weapons,Hunting Gear

19 BOOTS

20 WHISTLE

95 OTHER (Specify) RECORD RESPONSE

97 DON’T KNOW

99 REFUSED

I3. How often do you update these supplies? Would you say…

01 NEVER

02 LESS THAN ONCE A YEAR

03 ONCE A YEAR

04 MORE THAN ONCE A YEAR

97 DON’T KNOW

99 REFUSED

I4. Do you have supplies set aside in your car to be used only in the case of a disaster?

01 YES

02 NO

03 DON’T OWN A CAR

97 DON’T KNOW

99 REFUSED

Ask if respondent has a full-time or part-time job

I5. Do you have supplies set aside in your workplace to be used only in the case of a disaster?

01 YES

02 NO

97 DON’T KNOW

99 REFUSED

Make a Plan: Household Plan

J1. Has your household developed and discussed an emergency plan that includes Does your household have an emergency plan that includes instructions for household members about where to go and what to do in the event of a local disaster?

01 YES

02 NO

97 DON’T KNOW

99 REFUSED

Ask if the respondent’s household has an emergency plan with instructions for where household members should go and what they should do in the event of a disaster

J2. Have you discussed this plan with other members in your household?

01 YES

02 NO

97 DON’T KNOW

99 REFUSED

J4. Does your plan include the location of a safe and effective shelter in case of a tornado or high wind event __________?

(Interviewer: read B5A-B5C)

1	Yes
2	No
3	(DK)
4	(Refused)
4	(Refused)

B5A	QID:229104	At home	B5A(2181)
B5B	QID:229106	At work	B5B(2182)
B5C	QID:229105	At school	B5C(2183)

J5. Does your plan include information about how to leave your community for an evacuation?

1	Yes
2	No
3	(DK)
4	(Refused)

J6. Does your plan include checking on your neighbors (those in your neighborhood or apartment building) to make sure they are okay in the event of a disaster?

1	Yes
2	No
3	(DK)
4	(Refused)

J7. Do you know how you will get real-time alerts and warnings for disasters in your community?

1	Yes
2	No
3	(DK)
4	(Refused)

J3. Do you have copies of important identity and financial documents located with a trusted out-of-state friend or relative or in a password protected electronic form you can access by computer to help you recover after a disaster?

IF NECESSARY: These documents include identity documents like your social security card and driver’s license and financial documents like your insurance policies.

IF NECESSARY: Accessible by computer could be a computer drive, a USB drive, which is also known as a thumb drive, your portable music player or phone or a web-based back up or file storage system.

INTERVIEWER NOTE: If they have stored documents, but they are not password protected, the answer is “no.”

01 YES

02 NO

97 DON’T KNOW

99 REFUSED

Be Informed: Community Plans

K1. Using a scale of 1 to 5 with 5 being “very familiar” and 1 being “not at all familiar,” how familiar are you with… 

Items a-e, below, should be randomized

1. Alert and warning systems in your community?

2. Your community’s plans for evacuation?

3. Your community’s plans for sheltering?

4. Information on what your local hazards are?

5. Official sources of public safety information?

6. How to get help with evacuating or getting to a shelter?

7. How to get local information about a public health emergency, such as the H1N1 virus or swine flu?

05 VERY FAMILIAR

04

03

02

01 NOT AT ALL FAMILIAR

97 DON’T KNOW

99 REFUSED

[Ask if a child who lives in the home attends school]

K2. Have you received information from your child(ren)’s school about its disaster preparedness plan including evacuation and shelter plans?

01 YES

02 NO

97 DON’T KNOW

99. REFUSED

Be Informed: Drills

L1. Aside from a fire drill, in the past 12 months, have you participated in any of the following?

Items a-f, below, should be randomized

1. A home evacuation drill

2. A home shelter in place drill

3. [Ask if respondent has a full-time or part-time job]

4. A workplace evacuation drill

5. [Ask if respondent has a full-time or part-time job]

A workplace shelter in place drill

[Ask if respondent is a student or has child in school]

A school evacuation drill

[Ask if respondent is a student or has child in school]

A school shelter in place drill

01 YES

02 NO

97 DON’T KNOW

99 REFUSED

In the past year, have you participated in a preparedness exercise or drill at your workplace, school, home or other community location?

1	Yes
2	No
3	(DK)
4	(Refused)

L2. In the past year, have you practiced what to do in a disaster by participating in a disaster preparedness exercise or drill __________?

(Interviewer: read and rotate B3A-B3D)

1	Yes
2	No
3	(DK)
4	(Refused)

B3A	QID:229090	At home	B3A(2151)
B3B	QID:229093	At work	B3B(2152)
B3C	QID:229092	At school	B3C(2153)
B3D	QID:229091	At another community location	B3D(2154)

L3. Have you participated in any of the following types of drills or exercises?

(Interviewer: Read and rotate B3_1A-B3_1C)

1	Yes
2	No
3	(DK)
4	(Refused)

B3_1A	QID:229097	Fire or building evacuation	B3_1A(2161)
B3_1B	QID:229099	Earthquake, Drop Cover Hold On	B3_1B(2162)
B3_1C	QID:229098	Tornado	B3_1C(2163)

Volunteerism

M1. During the past 12 months, have you given any time to help support emergency responder organizations or an organization that focuses on community preparedness and safety?

01 YES

02 NO

97 DON’T KNOW

99 REFUSED

M3. Have you ever volunteered to help in a disaster?

01 YES

02 NO

97 DON’T KNOW

99. REFUSED

Sources of Information

//ASK ALL//

RECINFO. In the past six months, have you read, seen, or heard any information about how to get better prepared for a disaster?

01 YES

02 NO

97 DON’T KNOW

99 REFUSED

RECINFO1. What was it that you read, saw, or heard about how to get better prepared for a disaster? By disaster, I mean events that could threaten lives, disrupt public or emergency services like water and power, or damage property. (Open ended)

PREPARE. In the past six months, have you read, seen, or heard anything about PrepareAthon or America’s PrepareAthon?

1	Yes
2	No
3	(DK)
4	(Refused)

PREPSOUR. What was the source of this information?

(Interviewer: Open ended and code)

(Interviewer: If necessary, probe:) TV program, roadside billboard, Internet site)

01	Anywhere else (list)
02	(DK)
03	(Refused)
04	HOLD
05	HOLD
06	On national TV
07	On local TV
08	On the Internet
09	Through email
10	On the radio
11	In the newspaper
12	On social media
13	At church or from a faith-based organization
14	From a community organization
15	Through conversations with neighbors, friends, or family (online or offline)
16	At work
17	From your child’s school
18	From your school
19	From FEMA
20	From a local government entity or spokesperson
21	On the Ready.gov website

List Other:Y

INFOUSE2. Still thinking about those useful sources of information, Aafter receiving this information about how to get better prepared, did you take any steps to prepare for a disaster?

01 YES

02 NO

03 DIDN’T NEED TO TAKE STEPS; ALREADY PREPARED

97 DON’T KNOW

99 REFUSED

Knowledge of Protective Actions

NOTE: Protective actions are an area of specific interest for FEMA. There are a total of 8 hazard-specific protective actions sections below (i.e., hurricane, tornado, flood, heat, chemical release, earthquake, winter weather, and pandemic). Depending on the hazard-based profile of each respondent (i.e., where they live), they will be asked 0-4 of the following protective actions sections.

Hurricane Section

H1

What advice would you give to others on the best actions to take to protect themselves from a hurricane?

• (Interviewer: Open ended)

01	Other (list)
02	(DK)
03	(Refused)
04	HOLD
05	HOLD

H2

if a hurricane were threatening your area, what would prompt you to evacuate?

• (Interviewer: Open ended)

• (Programmer: Allow up to two responses)

01	Other (list)
02	(DK)
03	(Refused)
04	HOLD
05	HOLD

H3

Would you need assistance with transportation to evacuate?

1	Yes
2	No
3	(DK)
4	(Refused)

TORNADO SECTION

t1

• What advice would you give to others on the best actions to take to protect themselves from a tornado?

• (Interviewer: Open ended)

• 01	Other (list)
  02	(DK)
  03	(Refused)
  04	HOLD

• t2

• If a tornado warning were issued for your area right now, do you have underground shelter or a reinforced safe room where you would go?

1	Yes
2	No
3	(DK)
4	(Refused)

FLOOD SECTION

f1

What advice would you give to others on the BEST actions to take to protect themselves from being trapped by floods or injured by flood waters?

(Interviewer: Open ended)

01	Other (list)
02	(DK)
03	(Refused)
04	HOLD
05	HOLD

F2

If a flood were threatening your area, what would prompt you to evacuate?

(Interviewer: Open ended)

(Programmer: Allow up to two responses)

01	Other (list)
02	(DK)
03	(Refused)
04	(HOLD)
05	(HOLD)

F3

Would you need assistance with transportation to evacuate?

1	Yes
2	No
3	(DK)
4	(Refused)

HEAT SECTION

HE1

What advice would you give to others on the BEST actions to take to protect themselves when there is higher than usual heat and humidity for several days?

(Interviewer: Open ended)

01	Other (list)
02	(DK)
03	(Refused)
04	HOLD
05	HOLD

HE2

If a heat advisory were issued for your area and you did NOT have access to air conditioning, what are some of the things you would do?

(Interviewer: Open ended)

(Programmer: Allow up to two responses)

01	Other (list)
02	(DK)
03	(Refused)
04	HOLD
05	HOLD

CHEMICAL RELEASE SECTION

HA1

What advice would you give to others on the BEST actions to take to protect themselves from chemical fumes in your building (get to clean air, protect airways on the way, evac or open windows if evac not possible)?

(Interviewer: Open ended)

01	Other (list)
02	(DK)
03	(Refused)
04	HOLD
05	HOLD

HA2

What are two kinds of accidents that may result in people being exposed to hazardous materials? (transportation (train, truck), factories, household)

(Interviewer: Open ended)

(Programmer: Allow up to two responses)

01	Other (list)
02	(DK)
03	(Refused)
04	HOLD
05	HOLD

EARTHQUAKE SECTION

EQ1

What advice would you give to others on the BEST actions to take to protect themselves when the building they are in starts to shake and you think it’s an earthquake?

(Interviewer: Open ended)

01	Other (list)
02	(DK)
03	(Refused)
04	HOLD
05	HOLD

EQ2

What are three things you can do in your home or office building in advance to reduce the likely danger of failing debris in an earthquake? (anchor shelving, move heavy items/lights over beds, anchor items on walls)

(Interviewer: Open ended)

(Programmer: Allow up to three responses)

01	Other (list)
02	(DK)
03	(Refused)
04	HOLD
05	HOLD

WINTER STORM

W1

What advice would you give to others on the BEST actions to take to protect themselves when a winter storm is predicted?

(Interviewer: Open ended)

01	Other (list)
02	(DK)
03	(Refused)
04	HOLD
05	HOLD

WS2

Name two ways that people get carbon monoxide poisoning when the power is out and its cold? (using generator, gas stove, grill, etc. inside for heat)

(Interviewer: Open ended)

(Programmer: Allow up to two responses)

01	Other (list)
02	(DK)
03	(Refused)
04	HOLD
05	HOLD

PANDEMIC SECTION

PA1

What advice would you give to others on the BEST actions to take to protect themselves from a pandemic?

(Interviewer: Open ended)

01	Other (list)
02	(DK)
03	(Refused)
04	HOLD
05	HOLD

PA2

Name two ways that pandemic flu is different from seasonal flu?

(Interviewer: Open ended)

(Programmer: Allow up to two responses)

01	Other (list)
02	(DK)
03	(Refused)
04	HOLD
05	HOLD

Demographics

Lastly, I would like to ask you for some information about you and your household. Again, all information that you provide will be held confidential.

N2. Is your home?Do you rent or own your home?

01 OWNED

02 RENTED

03 LIVE THERE WITHOUT PAYING RENT

97 DON’T KNOW

99 REFUSED

N4. What is the highest level of education that you attained? Would it be…?

01 LESS THAN 12^TH GRADE (NO DIPLOMA)high school diploma

02 HIGH SCHOOL GRADUATE OR GEDdegree or diploma

03

Technical/Vocational school

SOME COLLEGE BUT NO DEGREE

04 ASSOCIATE DEGREE INSome COLLEGE

05 BACHELOR’S DEGREECollege graduate

06 MASTERS DEGREEPost graduate work or degree

07 DOCTORATE DEGREE

97 DON’T KNOW

99 REFUSED

DIS1. Do you have a disability or a health condition that might affect your capacity to prepare for an emergency situation?

IF NECESSARY: A mobility, hearing, vision, cognitive, or intellectual disability or physical, mental or health condition

01 YES

02 NO

97 DON’T KNOW

99 REFUSED

DIS2. Do you have a disability or a health condition that might affect your capacity to respond to an emergency situation?

IF NECESSARY: A mobility, hearing, vision, cognitive, or intellectual disability or physical, mental or health condition

01 YES

02 NO

97 DON’T KNOW

99 REFUSED

DIS3. Do you currently live with or have primary responsibility for assisting someone with a disability who requires assistance? Do you currently help care for an elderly or disabled family member, relative or friend or not?

01 YES

02 NO

97 DON’T KNOW

99 REFUSED

N7. Which of the following best describes your race? Would you consider yourself to be…?

01	WHITE
02	BLACK OR AFRICAN-AMERICAN
03	ASIAN
04	AMERICAN INDIAN OR ALASKA NATIVE, OR
05	NATIVE HAWAIIAN OR PACIFIC ISLANDER

01 WHITE

02 BLACK OR AFRICAN AMERICAN

03 ASIAN

04 AMERICAN INDIAN OR ALASKA NATIVE

05 NATIVE HAWAIIAN OR OTHER PACIFIC ISLANDER

95 SOMETHING ELSE (SPECIFY) RECORD RESPONSE

97 DON’T KNOW

99 REFUSED

N8. Are you of Hispanic or Latino or Spanish origin – such as Mexican, Puerto Rican, Cuban or other Spanish origin?

01 YES

02 NO

97 DON’T KNOW

99 REFUSED

N9. In what year were you born?Please tell me your age.

Enter response _ _ _ _

9997 DON’T KNOW

9999 REFUSED

N10. What is your total MONTHLY household income, before taxes? Please include income from wages and salaries, remittances from family members living elsewhere, farming, and all other sources. Interviewer: Open ended and code)

(Interviewer: [(If response is greater than $10,000, read:) Is that a monthly or an annual amount? (If monthly, code as appropriate; if annual, probe for monthly amount)])

01	Under $60
02	$60 to $499
03	$500 to $999
04	$1,000 to $1,999
05	$2,000 to $2,999
06	$3,000 to $3,999
07	$4,000 to $4,999
08	$5,000 to $7,499
09	$7,500 to $9,999
10	$10,000 to $14,999
11	$15,000 to $19,999
12	$20,000 and over
98	(DK)
99	(Refused)

Which of the following income ranges represents your annual household income in 2010? Feel free to stop me at the correct range. Was your household income…?

01 Less than $25,000

02 $25,000 to less than $50,000

03 $50,000 to less than $75,000

04 $75,000 or more

97 DON’T KNOW

99 REFUSED

D14

QID:172164 Is your total MONTHLY household income before taxes $4,000 or more, or is it less than $4,000?

(Interviewer:
(If under, ask:) Is it over or under $3,000?
(If under, ask:) Is it over or under $2,000?
(If under, ask:) Is it over or under $1,000?
(If under, ask:) Is it over or under $500?
(If under, ask:) Is it over or under $60?)

(Interviewer:
(If over, ask:) Is it over or under $5,000?
(If over, ask:) Is it over or under $7,500?
(If over, ask:) Is it over or under $10,000?
(If over, ask:) Is it over or under $15,000?
(If over, ask:) Is it over or under $20,000?)

01	Under $60
02	$60 to $499
03	$500 to $999
04	$1,000 to $1,999
05	$2,000 to $2,999
06	$3,000 to $3,999
07	$4,000 to $4,999
08	$5,000 to $7,499
09	$7,500 to $9,999
10	$10,000 to $14,999
11	$15,000 to $19,999
12	$20,000 and over
98	(DK)
99	(Refused)

N11. What state do you live in?is the name of the state you live in?

Enter response _ _

9997 DON’T KNOW

9999 REFUSED

N12.

May I have your ZIP code?

May I haveWhat is your zip code?

Enter response _ _ _ _ _

9997 DON’T KNOW

9999 REFUSED

N13. What is the name of the county you live in?

Enter response _ _ _ _ _

9997 DON’T KNOW

9999 REFUSED

N13N14. Record gender [Do not ask]

01 MALE

02 FEMALE

Questions about cell phones

Ask if the respondent wants to continue with the survey and is on a landline

Cell1. Do you personally use a cell phone?have a cell phone that you use to make and receive personal calls?

01 YES

02 NO

97 Don’t Know

99 REFused

Questions about landlines

Ask if the respondent wants to continue with the survey and is on a cell phone

LL1. Do you have at least one landline telephone line in your home that you use for making and receiving phone calls?a regular, landline telephone in your home that you use to make and receive personal calls?

IF NECESSARY: A landline is a traditional phone, not a cell phone.

IF NECESSARY: We only want to know about the lines you actually use to make calls, not lines dedicated to internet or fax.

01 YES

02 NO

97 Don’t know

99 REFused

D10

QID:172154 As far as you know, is that landline telephone number a listed or unlisted number?

(Interviewer: IF RESPONDENT HAS MORE THAN ONE LANDLINE NUMBER, ASK ABOUT THE ONE THEY USE MOST OFTEN AT HOME)

1	Listed
2	Unlisted
3	(DK)
4	(Refused)

QID:229153 Skip: (If code 2 in QNS1, Autcode D11 as 1 and Continue with Note before D12;
Otherwise, Continue)

D11

QID:172157 Do you have a cell phone that you use to make and receive personal calls?

1	Yes
2	No
3	(DK)
4	(Refused)

Questions about dual usage

Ask if respondent wants to continue with the survey and is on either a cell phone or a landline

Dual1. Of all the telephone calls that you receive, are…

01 ALL OR ALMOST ALL CALLS RECEIVED ON CELL PHONES

02 SOME RECEIVED ON CELL PHONES AND SOME ON REGULAR

PHONES, OR

03 VERY FEW OR NONE ON CELL PHONES

97 Don’t Know

99 REFused

CLOSE1. Those are all of the questions that I have. On behalf of Research Company and FEMA, I would like to thank you for your time and participation. Thank you again.

FEMA Form 008-0-15 37