Household Survey and Consent

OMB Control No: 0920-0993

Expiration Date: 09/30/2015

Attachment D: Household Survey for General Public and Consent

Public reporting burden of this collection of information is estimated to average 25 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 Information Collection Review Office; 1600 Clifton Road NE, MS D-74, Atlanta, Georgia 30333; ATTN:  PRA (0920-0993)

//ASK ALL//

YOURTHE1. You may choose not to answer any question you don't want to answer or stop at any time.  Any information you give me will be kept private.  Your responses will be combined with others from your community and will not be linked back to you. This call may be monitored and recorded for quality control. I'd like to continue now unless you have any questions. [INTERVIEWER: IF NEEDED: The interview takes an average 25 minutes to complete depending on your answers.]

[INTERVIEWER TYPE SUSPEND FOR CALLBACK APPOINTMENT]

01 Person Interested, continue

//ASK ALL//

OMB. Public reporting burden of this collection of information is estimated to average 25 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 Information Collection Review Office; 1600 Clifton Road NE, MS D-74, Atlanta, Georgia 30333; ATTN:  PRA (0920-0993)

01 Continue

//ASK ALL//

GEND. I’m sorry but I have to ask. What is your gender?

01 Male

02 Female

//ASK IF CONF1=2,97,99//

Life Satisfaction and Emotional Support

//ASK ALL//

Q1. In general, how satisfied are you with your life? Are you very dissatisfied, dissatisfied, satisfied, or very satisfied?

01 Very dissatisfied

02 Dissatisfied

03 Satisfied

04 Very Satisfied

97 DON’T KNOW

99. REFUSED

//ASK ALL//

Q2. How often do you get the social and emotional support that you need? Would you say, always, usually, sometimes, rarely, never?

01 Always

02 Usually

03 Sometimes

04 Rarely

05 Never

97 DON’T KNOW

99 REFUSED

//ASK ALL//

Q3. How often do you get the health and medical care that you need?

[INTERVIEWER: Read list if necessary]

01 Always

02 Usually

03 Sometimes

04 Rarely

05 Never

97 DON’T KNOW

99 REFUSED

Life Orientation Test-Revised

//ASK ALL//

PREQ4. Please answer the following questions about yourself by indicating the extent of your agreement using the following scale: Strongly disagree, Disagree, Neither Agree nor Disagree, Agree, or Strongly agree.

01 Continue

//ASK ALL//

Q4. In uncertain times, I usually expect the best. [IF NECESSARY: “Do you strongly disagree, disagree, neither agree nor disagree, agree, or strongly agree?”]

1. Strongly Disagree

2. Disagree

3. Neither Agree nor Disagree

4. Agree

5. Strongly Agree

97 DON’T Know

99 REFUSED

//ASK ALL//

Q5. I’m always optimistic about my future. [IF NECESSARY: “Do you strongly disagree, disagree, neither agree nor disagree, agree, or strongly agree?”]

1. Strongly Disagree

2. Disagree

3. Neither Agree nor Disagree

4. Agree

5. Strongly Agree

97 DON’T KNOW

99 REFUSED

//ASK ALL//

Q6. I hardly ever expect things to go my way. [IF NECESSARY: “Do you strongly disagree, disagree, neither agree nor disagree, agree, or strongly agree?”]

1. Strongly Disagree

2. Disagree

3. Neither Agree nor Disagree

4. Agree

5. Strongly Agree

97 DON’T KNOW

99 REFUSED

//ASK ALL//

Q7. I rarely count on good things happening to me. [IF NECESSARY: “Do you strongly disagree, disagree, neither agree nor disagree, agree, or strongly agree?”]

1. Strongly Disagree

2. Disagree

3. Neither Agree nor Disagree

4. Agree

5. Strongly Agree

97 DON’T KNOW

99 REFUSED

Social Connectedness

//ASK ALL//

Q8. I am happy with the friendships I have. [IF NECESSARY: “Do you strongly disagree, disagree, neither agree nor disagree, agree, or strongly agree?”]

1. Strongly Disagree

2. Disagree

3. Neither Agree nor Disagree

4. Agree

5. Strongly Agree

97 DON’T KNOW

99 REFUSED

//ASK ALL//

Q9. I have people with whom I can do enjoyable things. [IF NECESSARY: “Do you strongly disagree, disagree, neither agree nor disagree, agree, or strongly agree?”]

1. Strongly Disagree

2. Disagree

3. Neither Agree nor Disagree

4. Agree

5. Strongly Agree

97 DON’T KNOW

99 REFUSED

//ASK ALL//

Q10. I feel I belong in my community. [IF NECESSARY: “Do you strongly disagree, disagree, neither agree nor disagree, agree, or strongly agree?”]

1. Strongly Disagree

2. Disagree

3. Neither Agree nor Disagree

4. Agree

5. Strongly Agree

97 DON’T KNOW

99 REFUSED

//ASK ALL//

Q11. In a crisis, I would have the support I need from family or friends. [IF NECESSARY: “Do you strongly disagree, disagree, neither agree nor disagree, agree, or strongly agree?”]

1. Strongly Disagree

2. Disagree

3. Neither Agree nor Disagree

4. Agree

5. Strongly Agree

97 DON’T KNOW

99 REFUSED

Neighborhood Disorder Scale

//ASK ALL//

PREQ12.Next I would like to ask you some questions about your neighborhood. Again, please tell me your level of agreement.

1. Continue

//ASK ALL//

Q12. My neighborhood is safe. [IF NECESSARY: “Do you strongly disagree, disagree, neither agree nor disagree, agree, or strongly agree?”]

1. Strongly Disagree

2. Disagree

3. Neither Agree nor Disagree

4. Agree

5. Strongly Agree

97 DON’T KNOW

99 REFUSED

//ASK ALL//

Q13.My neighborhood is clean. [IF NECESSARY: “Do you strongly disagree, disagree, neither agree nor disagree, agree, or strongly agree?”]

1. Strongly Disagree

2. Disagree

3. Neither Agree nor Disagree

4. Agree

5. Strongly Agree

97 DON’T KNOW

99 REFUSED

//ASK ALL//

Q14. I can trust most people in my neighborhood. [IF NECESSARY: “Do you strongly disagree, disagree, neither agree nor disagree, agree, or strongly agree?”]

1. Strongly Disagree

2. Disagree

3. Neither Agree nor Disagree

4. Agree

5. Strongly Agree

97 DON’T KNOW

99 REFUSED

Collective Efficacy Scale

//ASK ALL//

PREQ15. The next few questions will ask you to respond using the following rating scale, very unlikely, unlikely, neither likely nor unlikely, likely, or very likely?

01 Continue

//ASK ALL//

Q15. If a group of children were skipping school and hanging out on a street corner, how likely is it that your neighbors would do something about it? [IF NECESSARY: “Would you say it is very likely, likely, neither likely nor unlikely, unlikely, or very unlikely?”]

1. Very Unlikely

2. Unlikely

3. Neither likely nor unlikely

4. Likely

5. Very Likely

97 DON’T KNOW

99. REFUSED

//ASK ALL//

Q16. If some children were spray-painting graffiti on a local building, how likely is it that your neighbors would do something about it? [IF NECESSARY: “Would you say it is very likely, likely, neither likely nor unlikely, unlikely, or very unlikely?”]

1. Very Unlikely

2. Unlikely

3. Neither likely nor unlikely

4. Likely

5. Very Likely

97 DON’T KNOW

99. REFUSED

//ASK ALL//

Q17. If there was a fight in front of your house and someone was being beaten or threatened, how likely is it your neighbors would break it up? [IF NECESSARY: “Would you say it is very likely, likely, neither likely nor unlikely, unlikely, or very unlikely?”]

1. Very Unlikely

2. Unlikely

3. Neither likely nor unlikely

4. Likely

5. Very Likely

97 DON’T KNOW

99. REFUSED

//ASK ALL//

Q18. If a child was showing disrespect to an adult, how likely is it that people in your neighborhood would scold that child? [IF NECESSARY: “Would you say it is very likely, likely, neither likely nor unlikely, unlikely, or very unlikely?”]

1. Very Unlikely

2. Unlikely

3. Neither likely nor unlikely

4. Likely

5. Very Likely

97 DON’T KNOW

99. REFUSED

//ASK ALL//

Q19. Suppose that because of budget cuts the fire station closest to your home was going to be closed down by the city. How likely is it that neighborhood residents would organize to try to do something to keep the fire station open? [IF NECESSARY: “Would you say it is very likely, likely, neither likely nor unlikely, unlikely, or very unlikely?”]

1. Very Unlikely

2. Unlikely

3. Neither likely nor unlikely

4. Likely

5. Very Likely

97 DON’T KNOW

99. REFUSED

//ASK ALL//

PREQ20. For each of these statements, please tell me whether you Strongly disagree, disagree, neither agree nor disagree, agree, or Strongly agree

01 Continue

//ASK ALL//

Q20. People around here are willing to help their neighbors. [IF NECESSARY: “Do you strongly disagree, disagree, neither agree nor disagree, agree, or strongly agree?”]

1. Strongly Disagree

2. Disagree

3. Neither agree nor disagree

4. Agree

5. Strongly Agree

97. DON’T KNOW

99 REFUSED

//ASK ALL//

Q21. This is a close-knit neighborhood. [IF NECESSARY: “Do you strongly disagree, disagree, neither agree nor disagree, agree, or strongly agree?”]

1. Strongly Disagree

2. Disagree

3. Neither agree nor disagree

4. Agree

5. Strongly Agree

97. DON’T KNOW

99 REFUSED

//ASK ALL//

Q22. People in this neighborhood generally don’t get along with each other. [IF NECESSARY: “Do you strongly disagree, disagree, neither agree nor disagree, agree, or strongly agree?”]

1. Strongly Disagree

2. Disagree

3. Neither agree nor disagree

4. Agree

5. Strongly Agree

97. DON’T KNOW

99REFUSED

//ASK ALL//

Q23. People in this neighborhood do not share the same values. [IF NECESSARY: “Do you strongly disagree, disagree, neither agree nor disagree, agree, or strongly agree?”]

1. Strongly Disagree

2. Disagree

3. Neither agree nor disagree

4. Agree

5. Strongly Agree

97. DON’T KNOW

99REFUSED

Economic Stability

//ASK ALL//

PREQ24. Now I’m going to ask some questions about your household.

1. Continue

//ASK ALL//

Q24. What is your estimated annual household income from all sources? Was it....

01 <$15,000

02 $15,000-<$20,000

03 $20,000-<$25,000

04 $25,000-<$35,000

05 $35,000-<$50,000

06 $50,000-<$75,000

07 >$75,000

97. DON’T KNOW

99 REFUSED

//ASK ALL//

Q25. What best describes your situation?

01 I have insurance to cover most of my losses from natural disasters or other catastrophic events

02 I have insurance to cover some of my losses from natural disasters or other catastrophic events

03 I have no insurance

97. DON’T KNOW

99 REFUSED

//ASK ALL//

Q26. Do you own or rent your home?

01 Own

02 Rent

03 Other arrangement

97 DON’T KNOW/NOT SURE

99 REFUSED

//ASK IF Q26=01,02//

Q27. How often in the past 12 months would you say you were worried or stressed about having enough money to pay your rent/mortgage? Would you say you were worried or stressed—

[INTERVIEWER NOTE: Read list]

01 Always

02 Usually

03 Sometimes

04 Rarely

05 Never

97 DON’T KNOW

99 REFUSED

//ASK ALL//

Q28. How often in the past 12 months would you say you were worried or stressed about having enough money to buy nutritious meals? Would you say you were worried or stressed---

01 Always

02 Usually

03 Sometimes

04 Rarely

05 Never

97. DON’T KNOW

99 REFUSED

Quality of Life

//ASK ALL//

PREQ29. Now I want to ask you some questions about your health.

01 Continue

//ASK ALL//

Q29. Thinking about your physical health, which includes physical illness and injury, for how many days during the past 30 days was your physical health not good?

_ _Number of days [RANGE= 1-30]

88 NONE

97. DON’T KNOW/NOT SURE

99 REFUSED

//ASK ALL//

Q30. Thinking about your mental health, which includes stress, depression, and problems with emotions, for how many days during the past 30 days was your mental health not good?

_ _Number of days [RANGE= 1-30]

88 NONE

97. DON’T KNOW/NOT SURE

99 REFUSED

Health Behaviors

//ASK ALL//

Q31. During the past 30 days, other than your regular job, did you participate in any physical activities or exercises such as running, calisthenics, golf, gardening, or walking for exercise?

01 Yes

02 No

97 DON’T KNOW

99 REFUSED

//ASK ALL//

Q32. During the past 30 days, how many days per week or per month did you have at least one drink of any alcoholic beverage?

1_ _ Days per week [RANGE = 101-107]

2 _ _ Days in past 30 days [RANGE = 201-230]

888. No drinks in past 30 days

997 DON’T KNOW/NOT SURE

999 REFUSED

//ASK IF Q32 NE 888,997,999//

Q33. Considering all types of alcoholic beverages, how many times during the past 30 days did you have X [X=5 FOR MEN, X=4 FOR WOMEN] or more drinks on an occasion?

__ number of times [ RANGE 1-76]

88 None

97. DON’T KNOW

99 REFUSED

//ASK IF Q32 NE 888,997,999//

Q34. One drink is equivalent to a 12-ounce beer, a 5-ounce glass of wine, or a drink with one shot of liquor. During the past 30 days, on the days when you drank, about how many drinks did you drink on the average? [A 40 ounce beer would count as 3 drinks, or a cocktail drink with 2 shots would count as 2 drinks.]

__ number of times [RANGE 1-76]

88 None

97. DON’T KNOW

99 REFUSED

//ASK ALL//

Q35. Have you smoked at least 100 cigarettes in your entire life? [Note: 5 packs = 100 cigarettes]

01 Yes

02 No

97 DON’T KNOW

97. EFUSED

//ASK ALL//

Q36. Do you now smoke cigarettes every day, some days, or not at all?

01 Every day

02 Some days

03 Not at all

97 DON’T KNOW

99 REFUSED

//ASK ALL//

Q37. In the past 30 days, have you increased your level of prescription or non-prescription medication use without the advice of a doctor or other health care professional?

01 Yes

02 No

97 DON’T KNOW

99 REFUSED

Anxiety and Depression

//ASK ALL//

PREQ38. Now, I am going to ask you some questions about your mood. When answering these questions, please think about how many days each of the following has occurred in the past 2 weeks.

01 Continue

//ASK ALL//

Q38. Over the last 2 weeks, how many days have you had little interest or pleasure in doing things?

_ _ Enter Number [RANGE 1–14]

88 None

97 DON’T KNOW/NOT SURE

99 REFUSED

//ASK ALL//

Q39. Over the last 2 weeks, how many days have you felt down, depressed or hopeless?

_ _ Enter Number [RANGE 1–14]

88 None

97 DON’T KNOW/NOT SURE

97. REFUSED

//ASK ALL//

Q40. Over the last 2 weeks, how many days have you had trouble falling asleep or staying asleep or sleeping too much?

_ _ Enter Number [RANGE 1–14]

88 None

97 DON’T KNOW/NOT SURE

99 REFUSED

//ASK ALL//

Q41. Over the last 2 weeks, how many days have you felt tired or had little energy?

_ _ Enter Number [RANGE 1–14]

88 None

97 DON’T KNOW/NOT SURE

99 REFUSED

//ASK ALL//

Q42. Over the last 2 weeks, how many days have you had a poor appetite or eaten too much?

_ _ Enter Number [RANGE 1–14]

88 None

97 DON’T KNOW/NOT SURE

99 REFUSED

//ASK ALL//

Q43. Over the last 2 weeks, how many days have you felt bad about yourself or that you were a failure or had let yourself or your family down?

_ _ Enter Number [RANGE 1–14]

88 None

97 DON’T KNOW/NOT SURE

99 REFUSED

//ASK ALL//

Q44. Over the last 2 weeks, how many days have you had trouble concentrating on things, such as reading the newspaper or watching the TV?

_ _ Enter Number [RANGE 1–14]

88 None

97 DON’T KNOW/NOT SURE

99 REFUSED

//ASK ALL//

Q45. Over the last 2 weeks, how many days have you moved or spoken so slowly that other people could have noticed? Or the opposite – being so fidgety or restless that you were moving around a lot more than usual?

_ _ Enter Number [RANGE 1–14]

88 None

97 DON’T KNOW/NOT SURE

99 REFUSED

Generalized Anxiety Disorder (from GAD-7)

//ASK ALL//

PREQ46. I apologize if these questions seem redundant, please bear with me. Over the last two weeks, for how many days have you been bothered by the following problems….

1. Continue

//ASK ALL//

Q46. Over the last 2 weeks, how many days have you been nervous, anxious, or on edge?

_ _ Enter Number [RANGE 1–14]

88 None

97 DON’T KNOW/NOT SURE

99 REFUSED

//ASK ALL//

Q47. Over the last 2 weeks, how many days have you not been able to stop or control worrying?

_ _ Enter Number [RANGE 1–14]

88 None

97 DON’T KNOW/NOT SURE

99 REFUSED

//ASK ALL//

Q48. Over the last 2 weeks, how many days have you worried too much about different things?

_ _ Enter Number [RANGE 1–14]

88 None

97 DON’T KNOW/NOT SURE

99 REFUSED

//ASK ALL//

Q49. Over the last 2 weeks, how many days have you had trouble relaxing?

_ _ Enter Number [RANGE 1–14]

88 None

97 DON’T KNOW/NOT SURE

99 REFUSED

//ASK ALL//

Q50. Over the last 2 weeks, how many days have you been so restless that it was hard to sit still?

_ _ Enter Number [RANGE 1–14]

88 None

97 DON’T KNOW/NOT SURE

99 REFUSED

//ASK ALL//

Q51. Over the last 2 weeks, how many days have you been easily annoyed or irritable?

_ _ Enter Number [RANGE 1–14]

88 None

97 DON’T KNOW/NOT SURE

99 REFUSED

//ASK ALL//

Q52. Over the last 2 weeks, how many days have you felt afraid as if something awful might happen?

_ _ Enter Number [RANGE 1–14]

88 None

97 DON’T KNOW/NOT SURE

99 REFUSED

//ASK ALL//

Q54. Has a doctor or other healthcare provider EVER told you that you have an anxiety disorder (including acute stress disorder, anxiety, generalized anxiety disorder, obsessive-compulsive disorder, panic disorder, phobia, posttraumatic stress disorder, or social anxiety disorder)?

01 Yes

02 No

97 DON’T KNOW/NOT SURE

99 REFUSED

//ASK ALL//

Q55. Has a doctor or other healthcare provider EVER told you that you have a depressive disorder (including depression, major depression, dysthymia, or minor depression)?

INTERVIEWER NOTE: Dysthymia pronounced dis-THIE-me-uh

01 Yes

02 No

97 DON’T KNOW/NOT SURE

99 REFUSED

//ASK ALL//

Q56. Are you now taking medicine or receiving treatment from a doctor or other health professional for any type of mental health condition or emotional problem?

01 Yes

02 No

97 DON’T KNOW/NOT SURE

99 REFUSED

Mental Health Treatment

//ASK ALL//

Q57. Have you EVER received any sort of counseling for problems with your emotions, nerves, or mental health? Please include counseling from a family doctor, psychiatrist, psychologist, social worker, therapist, or clergy.

01 Yes

02 No

97 DON’T KNOW/NOT SURE

99 REFUSED

//ASK IF Q57=1//

Q58. In the past year, how many times have you received counseling for problems with emotions, nerves, or mental health?

__number [RANGE 1-365]

888 Hasn’t received counseling within the past year

997 DON’T KNOW/NOT SURE

999 REFUSED

//ASK ALL//

Q59. Were you EVER prescribed medication for problems with your emotions, nerves, or

mental health?

01 Yes

02 No

97 DON’T KNOW/NOT SURE

99 REFUSED

//ASK IF Q59=1//

Q59B. When were you first prescribed medication for problems with your emotions, nerves, or

mental health?

01 Within the past month- that is, anytime less than 1 month ago.

02 Within the past year- that is, equal to or more than 1 month but less than 12 months ago.

03 Within the past 2 years- that is, equal to or more than 1 year but less than 2 years ago.

04 Within the past 3 years- that is, equal to or more than 2 years but less than 3 years ago

05 Three or more years ago.

97 DON’T KNOW/NOT SURE

99 REFUSED

Children’s Mental Health

//ASK ALL//

Q60. How many children less than 18 years of age live in your household?

_____ ENTER NUMBER [RANGE 1-15]

88 NONE

97 DON’T KNOW

99 REFUSED

//ASK IF Q60 NE 88, 97, 99//

Q61. During the past 30 days, have any of the children in your household experienced any of the following difficulties:

Q61A. Been very sad or depressed?

Q61B. Felt nervous or afraid?

Q61C. Problems sleeping?

Q61D. Problems getting along with other children?

1. YES

2. NO

97. DON’T KNOW/NOT SURE

99 REFUSED

Access to Health Services

//ASK ALL//

Q62. Do you have any kind of health care coverage, including health insurance, prepaid plans such as HMOs, or government plans such as Medicare or Indian Health Services?

01 Yes

02 No

97 DON’T KNOW/NOT SURE

99 REFUSED

//ASK IF Q62=01//

Q62A. Does your health care plan include mental health coverage?

01 Yes

02 No

97 DON’T KNOW/NOT SURE

99 REFUSED

//ASK ALL//

Q63. Do you have one person you think of as your personal doctor or health care provider? [If “No,” ask: “Is there more than one, or is there no person who you think of as your personal doctor or health care provider?”]

01 Yes, only one

02 More than one

03 No

97 DON’T KNOW/NOT SURE

99 REFUSED

//ASK ALL//

Q64. Was there a time in the past 12 months when you needed to see a doctor but could not because of cost?

01 Yes

02 No

97 DON’T KNOW/NOT SURE

99 REFUSED

Tornado Exposure

//ASK ALL//

PREQ65. Now I’m going to ask some questions about the large tornado outbreak in the Southeast, during April 25-27, 2011.

01 CONTINUE

//ASK ALL//

//MUL=2//LNGTH. How long have you lived in this community?

[Read if necessary: By community, we mean how long have you lived in the same general area, such as the same town or the same county.]

01 response given in years

02 response given in months

97 DON’T KNOW/NOT SURE

99 REFUSED

//ASK IF LNGTH=01//

LNGTH2. How long have you lived in this community?

01 ________ Enter years [1-100]

ASK IF LNGTH=02//

LNGTH3. How long have you lived in this community?

1. _________ Enter Months [1-11]

//Ask All//

LVD. Did you live at this same address during the time of the tornadoes in April 2011?

01 YES

02 NO

97 DON’T KNOW/NOT SURE

99 REFUSED

//Ask if LVD = 02/97/99 ///

LVDZIP. In what zip code did you live in April 2011?

______[Range=5]

99997 DON’T KNOW

99999 REFUSED

//Ask if LVDZIP = 99997,99999//

LVST. Did you live in <insert STATE>

1. YES

2. NO

97 DON’T KNOW/NOT SURE

99 REFUSED

//Ask If LVST = 01//

LVDCTY. Do you recall what county you lived in?

01 Franklin/Marion

02 Jefferson

03 Tucaloosa

04 Chicksaw/Monroe

88 County not in area

97 DON'T KNOW/NOT SURE

99 REFUSED

//ASK IF LVDZIP ne ELIGIBLE ZIPS OR LVDCTY = 88/97/99

Q65a. Did you live in or near an area impacted by the April 2011 tornadoes?

1. Yes

02 No

97 DON’T KNOW

99 REFUSED

//Create Variable InArea = 1 IF LVD = 01; InArea = 2 IF LVDZIP = ELIGIBLE ZIPS OR Q65a = 01; InArea = 3 IF LVST = 2/97/99 OR Q65a =2/97/99//

//Meaning - InArea = 1 was in area at same address; InArea = 2 was in area at different address; InArea = 3 wasn’t in area//

//ASK IF InArea = 2 or (IF InArea=1 and IF CONF1=2,97,99//

LVDST. In order to help us understand how close your home was to the areas hit by the tornadoes, we’d like to know what the nearest intersection to your home was in April 2011.  This information will only be used to group your responses with others from your neighborhood.  Please name the two cross-streets of this intersection.

[Interviewer note: If Respondents refuses – enter refuse on next screen]

1. Continue

//ASK IF LVDST=01//

LVDST1. What is the name of the first street?

INTERVIEWER NOTE: Confirm street spelling

01 Record Response

97 Don’t Know

99 Refused

//ASK IF LVDST1=01//

LVDST1A. What is the name of the first street?

_________ Enter response [RANGE=1-50]

//ASK IF LVDST1 =01//

LVDST2. What is the name of the second street?

[INTERVIEWER NOTE: Confirm street spelling]

01   Record Response

97  Don’t Know

99  Refused

//ASK IF LVDST2=01//

LVDST2A. What is the name of the second street?

_______ Enter Response [RANGE 1-50]

//ASK IF LVDST1=01 and LVDST2=01//

LVDST3 The streets I recorded for the closest intersection are: [insert LVDST1] and [insert LVDST2]. Is this correct?

01 Yes, both correct

02 No, both incorrect (go back to LVDST1/LVDST2]

03 No, first incorrect (go back to LVDST1)

04 No, second incorrect (go back to LVDST2)

//ASK InArea = 1 OR 2//Q66. Approximately how far away (in miles) from the closest tornado were you sheltered during the severe storms? Interviewer Note: If tornado “hit” you, please say “zero”

______ ENTER MILES [RANGE 0-200]

955 Less than a mile away

966 More than 200 miles away

997 DON’T KNOW

999 REFUSED

//ASK IF InArea = 1 OR 2//Q67. Approximately how far away (in miles) from your home was the closest tornado?

Interviewer Note: If tornado “hit” your home, please say “zero”

_____ ENTER MILES [RANGE 0-200]

955 Less than a mile away

966 More than 200 miles away

997 DON’T KNOW

999 REFUSED

//ASK IF InArea = 1 OR 2//

Q68. From April 25-27, during the tornado outbreak while your area was under tornado watch where were you?

01 At the place where I stayed or lived most of the time

02 At the home of a relative, in the area where I lived

03 At the home of a friend, in the area where I lived

04 At a designated shelter in the area where I lived

05 At another place

97. DON’T KNOW

99 REFUSED

//ASK IF InArea = 1 OR 2//

Q69. Did you feel safe where you were during the tornado watch and warnings?

01 Yes

02 No

03 Not sure

04 Not applicable

97 DON’T KNOW

99 REFUSED

//ASK IF InArea = 1 OR 2//

PREQ70. We understand that some of the next questions about your experiences during the tornado outbreak might be difficult. Please remember that you don’t have to answer any of the questions if you don’t want to.

1. CONTINUE

//Ask If InArea=3//

PREQ70a. These next questions relate to your experiences during the April 2011 tornado outbreak. We understand that some of the questions might not be relevant because you lived outside the area, but it’s possible that you may still have been affected by the tornadoes.

1. CONTINUE

//ASK IF InArea = 1 OR 2//Q70A. At any point during the time you were under tornado watch and warnings did you leave the place where you were?

ASK ALL

Q70B. At any point during the time you were under tornado watch and warnings did you feel direct threat to life of self or family member?

Q70C. Did you experience death of an immediate family member?

Q70D. Did you experience death of a friend or peer?

Q70E. Did you experience death of a pet?

Q70F. Did you experience any tornado related illness or physical injury of yourself or a family member?

//ASK IF InArea = 1 OR 2//

Q70G. Were you trapped by any tornadoes?

Q70H. Was your home not livable due to any tornadoes?

Q70I. Did you personally see any tornadoes?

Q70J. Did you require immediate rescue or emergency services following a tornado?

Q70K. Did you receive medical treatment for any illness or injury that occurred as a result of a tornado?

1. YES

2. NO

97. DON’T KNOW

99 REFUSED

Screening for DSM-IV PTSD

//ASK ALL//Q71A. Do you avoid being reminded of the tornado outbreak by staying away from certain places, people or activities?

Q71B. Have you lost interest in activities that were once important or enjoyable?

Q71C. Have you begun to feel more distant or isolated from other people?

Q71D. Do you find it hard to feel love or affection for other people?

Q71E. Have you begun to feel that there is no point in planning for the future?

Q71F. Have you had more trouble than usual falling or staying asleep?

Q71G. Do you become jumpy or easily startled by ordinary noise or movements?

1. YES

2. NO

97. DON’T KNOW

99 REFUSED

Community Involvement and Assistance

//ASK ALL////MUL=3//

Q72. Were you involved with any of the following before the April 2011 tornadoes?

[Interviewer: Multiple responses allowed]

1. School (for yourself or your children)

2. Church

3. Civic organizations (e.g. Boy or Girl Scouts, Rotary club, hobby clubs, VFW, volunteer groups, etc.)

4. No

97 DON’T Know

97. EFUSED

//ASK ALL////MUL=3//

Q73. Did you become involved with any of the following after the April 2011 tornadoes?

[Interviewer: Multiple responses allowed]

1. School (for yourself or your children)

2. Church

3. Civic organizations (e.g. Boy or Girl Scouts, Rotary club, hobby clubs, VFW, volunteer groups, etc.)

4. No

97 DON’T KNOW

99 REFUSED

//ASK IF InArea = 1 OR 2//Q74. For each of the following, please indicate the extent that the place/structure was damaged or destroyed as a result of the tornadoes using the following scale: Not affected at all, Minor damage or closed very briefly, Moderate damage or closed for a short period, Significant damage or closed for an extended period, Destroyed.

1. Continue

//If InArea=3//

Q74sub. For each of the following, please indicate the extent that the place/structure in your current community was damaged or destroyed as a result of the tornadoes using the following scale: Not affected at all, Minor damage or closed very briefly, Moderate damage or closed for a short period, Significant damage or closed for an extended period, Destroyed.

1. Continue

//ASK ALL//

Q74A. Your home

Q74B. The home of any close friends or family members

Q74C. Your workplace

Q74D. Your school or your child’s school

Q74E. Your church or place of worship

Q74F. Your regular places of recreation (shopping, parks, golf course, etc.)

Q74G. Your or your child’s doctor’s office

Q74H. Civic organizations (e.g. local non-profits, Boy or Girl Scouts, Rotary club, hobby clubs, VFW, volunteer groups, etc.)

[INTERVIEWER NOTE: Was it Not affected at all, Minor damage or closed very briefly, Moderate damage or closed for a short period, Significant damage or closed for an extended period, Destroyed].

01 Not affected at all

2. Minor damage or closed very briefly

3. Moderate damage or closed for a short period

4. Significant damage or closed for an extended period

5. Destroyed

6. Not applicable

97 DON’T KNOW

99 REFUSED

//ASK ALL//Q75. Did you receive any assistance in cleaning up or recovering from the tornado?

1. Yes

2. No

97 DON’T KNOW

99 REFUSED

//ASK IF Q75=1//

//MUL=7//

Q75A. Did you receive assistance from any of the following government organizations?[Interviewer: Multi responses allowed]

01 FEMA?

02 HUD?

03 National Guard or Coast Guard?

04 State agencies such as emergency management or state patrol?

05 Social service agency?

06 Local police or fire department?

7. or any other local government?

88 NONE

97 DON’T KNOW

99 REFUSED

//ASK IF Q75=1//

//MUL=7//

Q75B. Did you receive assistance from any of the following?

01 Family and/or Friends?

02 Neighbors?

03 Co-workers?

04 Strangers or new acquaintances?

05 Church or place of worship?

6. Red Cross?

7. Other?

88 NONE

97 DON’T KNOW

99 REFUSED

//ASK IF Q75B=07//

Q75BOTH. Please specify

______Enter Response [225character length]

//ASK ALL//

Q76. Did you assist anyone else with cleaning up or recovering from the tornadoes?

1. Yes

02 No

97 DON’T KNOW

99 REFUSED

//ASK IF Q76=1//

Q76A. Was this work done with a group such as your church or volunteer organization?

01 Yes (please specify the group or organization:___________________________)

2. No

97 DON’T KNOW/NOT SURE

99 REFUSED

//ASK IF Q76A=01//

Q76AOth. Please specify the group or organization.

_____Enter response [225 character length]

//ASK ALL////MUL=7//

Q77A. Besides yourself and your immediate household, do you feel you can rely on any of the following government agencies for assistance following a disaster?

[Interviewer: Multiple responses allowed]

01 FEMA?

02 HUD?

03 National Guard or Coast Guard?

04 State agencies such as emergency management or state patrol?

05 Social service agency?

6. Local police or fire department?

07 or any other local government?

88 NONE

97 DON’T KNOW

99 REFUSED

//ASK ALL////MUL=7//

Q77B. Besides yourself and your immediate household, who do you feel you can rely on outside of the government for assistance following a disaster?

[Interviewer: Multiple responses allowed]

01 Family and/or Friends?

02 Neighbors?

03 Co-workers?

04 Strangers or new acquaintances?

05 Church or place of worship?

06 Red Cross?

7. Other?

88 NONE

97 DON’T KNOW

99 REFUSED

Exposure to communication about the disaster and available resources

//ASK ALL////MUL=10//

Q78. Where did you get reliable information about emergency aid in the period immediately following the tornadoes?

[Interviewer: Multiple responses allowed]

01 Television

02 Radio

03 Internet

04 Automated call (e.g. reverse 911)

05 Text messages or smart phone alerts

06 Local newspaper

07 Church or other community group

08 Family, friend, neighbor/word of mouth

09 Flyer/Poster

10 Other

11 No agency, organization or person provided reliable information

12 Didn’t apply to me

97 DON’T KNOW

99 REFUSED

//ASK IF Q78 ne 11/12/97/99//Q79. Which of the following has been your most reliable source of information about assistance in trying to recover and rebuild following the tornadoes?

[PROGRAMMER: List only response options chosen in Q78]

01 Television

02 Radio

03 Internet

04 Automated Call (e.g. reverse 911)

05 Text messages or smart phone alerts

06 Local newspaper

07 Church or other community group

08 Family, friend, neighbor/word of mouth

09 Flyer/Poster

10 Other

11 No agency, organization or person provided reliable information

12 Didn’t apply to me

97 DON’T KNOW

97. REFUSED

//ASK IF CTY=01,02 OR N_CTY=01,02//

CTYFrMa. Were you aware that the following service was available in your area after the April 2011 tornadoes?

CTYFrMa1. The One Stop Assistance Center run by the Northwest Alabama Long Term Recovery Committee

CTYFrMa2. Camp Alabama Storm at Camp McDowell

CTYFrMa3. Project Rebound Counseling Services

CTYFrMa4. The shelter at First Baptist Church in Phil Campbell

CTYFrMa5. The triage and transport services run by Phil Campbell Rescue Squad

1. Yes

02 No

97 DON’T KNOW

99 REFUSED

//ASK IF CTY=03 OR N_CTY=03//

CTYJef. Were you aware that the following service was available in your area after the April 2011 tornadoes?

CTYJef1. Project Rebound Counseling Services

CTYJef2. Prescription drug voucher program from the County Health Department

CTYJef3. Dental services from the County Health Department

CTYJef4. Tetanus vaccine clinics run by the County Health Department

CTYJef5. Pratt City Disaster Relief Center at the old Scott School

CTYJef6. The shelter at Fairpark Arena

CTYJef7. The shelter at Boutwell Auditorium

CTYJef8. Grief support at Restoration Academy

1. Yes

02 No

97 DON’T KNOW

99 REFUSED

//ASK IF CTY=06 OR N_CTY=06//

CTYTus. Were you aware that the following service was available in your area after the April 2011 tornadoes?

CTYTus1. Project Rebound Counseling Services

CTYTus2. Counseling services offered by the University of Alabama

CTYTus3. Counseling offered by Family Counseling Services on Paul W. Bryant Drive

CTYTus4. Grief support at University Church of Christ

1. Yes

02 No

97 DON’T KNOW

99 REFUSED

//ASK IF CTY=04,05 OR N_CTY=04,05//

CTYChMo. Were you aware that the following service was available in your area after the April 2011 tornadoes?

CTYChMo1. The Disaster Recovery Center at Highway 23 and Highway 25 in Monroe County

CTYChMo2. The Disaster Recovery Center at the Houston Civic Center in Chickasaw County

CTYChMo3. The Prayer services organized by Pastor Wes White at the Smithville Baptist Church

CTYChMo4. Red Cross distribution of comfort and cleanup kits

CTYChMo5. The reconstruction services offered by Mennonite Disaster Services and the Long-term Recovery Committee

1. Yes

02 No

97 DON’T KNOW

99 REFUSED

Employment Status

//ASK ALL//Q81. How did the tornado outbreak affect your household income? Did it..

01 Decrease

02 Increase

03 No Change

97. DON’T KNOW

99 REFUSED

//ASK ALL//Q82. Including yourself, how many people in your household lost their jobs due to the tornado outbreak?

___Record number of people [ Range 1 – 18]

88 None

97 DON’T KNOW/NOT SURE

99 REFUSED

Perceived Recovery

//ASK ALL//Q83. In thinking about you, your family or other household members before and after the tornadoes, would you say your household is:

01 Better off than before the tornadoes

2. Recovered: Back to where it was before the tornadoes

03Recovering, Still slightly damaged from the tornadoes

04Recovering, Still damaged from the tornadoes

05Still very heavily damaged from the tornadoes

06 Experienced no change since before the tornadoes

97. DON’T KNOW

99 REFUSED

//ASK ALL//Q84. In thinking about your community before and after the tornadoes, would you say your community is:

01 Fully Recovered, Better off than before the tornadoes

02 Recovered, Back to where it was before the tornadoes

03 Recovering, Still slightly damaged from the tornadoes

04 Recovering, Still damaged from the tornadoes

05 Still very heavily damaged from the tornadoes

06 Experienced no change since before the tornadoes

97. DON’T KNOW

99 REFUSED

//ASK ALL//Q85. On a scale of 1-10 how well has your household recovered from the tornadoes?

___ Enter Response [Range 1-10]

97 DON’T KNOW

99 REFUSED

//ASK ALL//Q86. On a scale of 1-10 how well has your community recovered from the tornadoes?

__Enter Response [Range 1-10]

97 DON’T KNOW

99 REFUSED

//ASK ALL//Q87. Would you say your quality of life is (better) now than it was before the tornadoes, (worse) now, or is it about the same?

01 Better

02 Worse

03 About the same

97 DON’T KNOW

99 REFUSED

//ASK IF Q87=02//

Q87A. Is that mostly because of the after effects of the tornadoes, mostly because of the country’s recent economic problems, or mostly for other reasons?

01 Mostly because of the after effects of the tornadoes

02 Mostly because of the country’s recent economic problems

03 Mostly for other reasons

97 DON’T KNOW

99 REFUSED

//ASK ALL//Q88. Which of the following best describes your personal situation in terms of recovering from the tornadoes? Would you say that your day to day life is largely back to normal, almost back to normal, still somewhat disrupted, or still very disrupted?

01 Fully back to normal

02 Largely back to normal

03 Almost back to normal

04 Still somewhat disrupted

05 Still very disrupted

97 DON’T KNOW

99 REFUSED

//ASK ALL//Q89. Overall, would you say [your community] has mostly recovered from the tornadoes or not?

01 Yes, has mostly recovered

02 No, has not

97. ON’T KNOW

99REFUSED

//ASK ALL//Q90. As a place to live, would you say [your community] is (better) now than it was before the tornadoes, (worse) now than before the tornadoes, or back to being about the same as it was before the tornadoes?

01 Better

02 Worse

03 The same

97 DON’T KNOW

99 REFUSED

Demographics

//ASK ALL//

AGE. What is your age?

_ _ _ Age in years [Range 18-120]

997 DON’T KNOW

999. REFUSED

//ASK IF AGE=997 OR 999//

AGE2. In which of these age categories do you belong?

01 18-24

02 25-34

03 35-44

04 45-54

05 55-64

06 65-74

07 75-84

08 85 or older

97. DON’T KNOW

99 REFUSED

//ASK ALL//

ETH. Are you Hispanic or Latino?

01 Yes

02 No

97 DON’T KNOW/NOT SURE

99 REFUSED

//ASK ALL//

RACE. Which of these groups would you say represents your race? (Select all that apply)

[READ LIST]

01 American Indian or Alaska Native

02 Asian

03 Black or African American

04 Native Hawaiian or Other Pacific Islander

05 White

[DO NOT READ]

06 Respondent provides category of race not listed above

97. ON’T KNOW/NOT SURE

99 REFUSED

//ASK ALL//

EMPLOY. What is your employment status?

01 Employed for wages

02 Self-employed

03 Out of work for more than 1 year

04 Out of work for less than 1 year

05 A homemaker

06 A student

07 Retired

08 Unable to work

97 DON’T KNOW

99 REFUSED

//ASK ALL//

MAR. What is your current marital status?

01 Married

02 Divorced

03 Widowed

04 Separated

05 Never married

06 A member of an unmarried couple

97 DON’T KNOW

99 REFUSED

//ASK ALL//

ADULTS2. How many adults, including yourself, live in your household?

_____ ENTER RESPONSE [RANGE 1-18]

97 DON’T KNOW

99 REFUSED

//ASK IF ADULTS2 ne 97,99//

ADULTS2a. How many of these adults are male?

_____ ENTER RESPONSE [RANGE 0-ADULTS2]

97 DON’T KNOW

99 REFUSED

//ASK IF ADULTS2 ne 97,99//

ADULTS2b. How many of these adults are female?

_____ ENTER RESPONSE [RANGE 0-ADULTS2]

97 DON’T KNOW

99 REFUSED

//ASK IF (ADULTS2A=1-18 and ADULTS2B=1-18 AND ADULTS2=1-18) and ADULTS2a and ADULTS2b NE ADULTS2//

ADULTV. Interviewer: Number of males and females does not match total. Go back and correct this.

1. CONTINUE

//ASK ALL//GFTCD. Thank you for your participation. As a token of our appreciation, we’d like to provide you with a $10 Amazon Gift Code. This code can be used to make purchases on Amazon.com. Would you like me to provide you with the code now? Or would you prefer to call back at a later time?

01 Provide gift code

3. Will call back

99 REFUSED GIFT CODE

//IF GFTCD=01//

GFTCDa. Your gift code number is <insert gift code number>. Would you like me to repeat that?

[INTERVIEWER NOTE: Repeat number if requested]

01 Continue

//IF GFTCD=02//

GFTCDb. Please call 1-877-385-6205 to obtain your gift code number. You can either leave a message asking for a call-back, or speak to a representative to obtain the gift code number. Again the number is 1-877-385-6205.

[INTERVIEWER NOTE: Repeat number if requested]

01 Continue

//ASK ALL//

END. We have reached the end of the survey. Thank you for your participation in this important research.