Follow-up Survey - word

Attachment E: Follow-Up Survey

Form Approved

OMB No. 0920-XXXX

Exp. Date xx/xx/20xx

Public reporting burden of this collection of information is estimated to average 10 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-XXXX).

POST ASSESSMENT

INTRODUCTION

This survey is sponsored by OPHPR’s Learning Office as part of an education and training intervention. The purpose of this survey is to gather information about CDC employees’ current state of personal or household preparedness. This survey asks questions about your current state of personal or household preparedness, including potential threats, specific actions you have taken, and demographic information.

Your participation in the intervention, including this assessment, is completely voluntary and information you provide will be treated in a secure manner. You have been assigned a participant ID number; this number will be linked to your responses. No information you provide will be tied to your identity in any way. Generated reports will be in summary form only. Results will be used to test the usefulness of the education and training intervention only. It is intended that results will be shared in summary reports and developed for submission into scientific, peer-reviewed journals.

Please note that there are many questions that ask about disaster or emergencies, which are used interchangeably. For purposes of the current survey, the term “disaster” or “emergency” refers to events that could disrupt water, power, transportation, and also emergency and public services for up to three days (e.g., natural disasters, acts of terrorism, hazardous materials accidents, severe disease outbreak, etc.).

In addition, please answer questions in relation to your household. “Household” refers to your current residence and can include an individual, individual with family members, and individual with roommates, or individual with family and roommates.

Participant ID Number: XXYY

PERCEIVED PREPAREDNESS

These questions ask about being prepared for a disaster or emergency. “Prepared” refers to actions people can take at any time to prevent or reduce the impact of disasters or emergencies on their lives.

1. How well prepared do you feel your household is to handle a disaster or emergency?

• Not at All Prepared (0)

• Minimally Prepared (1)

• Prepared (2)

• Very Prepared (3)

• Extremely Prepared (4)

• Do Not know (88)

2. How confident are you that your local government is prepared to handle an emergency or disaster?

• Not at All Confident (0)

• Minimally Confident (1)

• Confident (2)

• Very Confident (3)

• Extremely Confident (4)

• Do Not Know (88)

EMERGENCY KIT

3. Which of the following statement best describes your household:

• My household is not aware of the need to assemble an emergency kit. (0)

• My household is aware of the need to assemble an emergency kit but does not intend to do it. (1)

• My household is aware of the need to assemble an emergency kit and intends to do it. (2)

• My household possesses an assembled emergency kit. (3)

• My household regularly maintains and updates an assembled emergency kit. (4)

3a. (If 1 or 2 above) Why has your household NOT assembled an emergency kit?

• Do not know what to include.

• Do not know where to locate information.

• Do not have the time.

• It costs too much.

• Do not have space to store a kit.

• Do not want to think about it.

• Do not think it will make a difference.

• Think that emergency responders, such as fire, police, or emergency personnel, will help.

• Other: Please Specify ______________________________________

4. Which of the following supplies does your household currently possess?

3-day supply of water for everyone who lives there (1 gallon of water per person per day)	3-day supply of nonperishable food for everyone who lives there (i.e., food that does not require refrigeration or cooking)	Copies of personal documents (medication list, medical information, passports, insurance policies, etc.)
Flashlight	7-day supply of medications	Family and emergency contact information
Battery-powered or hand-crank radio	Multi-purpose tool	Cash
Extra Batteries	Sanitation and personal hygiene items	Emergency blanket
First Aid Kit	Cell phone with chargers	Map(s) of area

EMERGENCY PLAN

5. Which of the following statement best describes your household:

• My household is not aware of the need to develop a written, emergency plan that includes instructions for household members about where to go and what to do. (0)

• My household is aware of the need to develop a written, emergency plan that includes instructions for household members about where to go and what to do, but does not intend to do it. (1)

• My household is aware of the need to develop a written, emergency plan that includes instructions for household members about where to go and what to do, and intends to do it. (2)

• My household possesses a written, emergency plan that includes instructions for household members about where to go and what to do. (3)

• My household regularly maintains and updates a written, emergency plan that includes instructions for household members about where to go and what to do. (4)

6. (If 3 or 4) Have you practiced the written, emergency plan that includes instructions for household members about where to go and what to do?

   • No (0)

   • Yes (1)

   • Do Not Know (88)

6a. (If Yes), When was the last time you practiced the written, emergency plan?

• More than 2 years ago (0)

• 1 – 2 years ago (1)

• 6 months – 1 year ago (2)

• 1 – 6 months ago (3)

• Within the past month (4)

• Do not Know (88)

(If 1, or 2) Why has your household NOT developed a written, emergency plan?

• Do not know what to include.

• Do not know where to locate information.

• Do not have the time.

• Do not want to think about it.

• Do not think it will make a difference.

• Think that emergency responders, such as fire, police, or emergency personnel, will help.

• Other: Please Specify ______________________________________

COMMUNITY INFORMATION & PLANNING

		No	Yes	Do Not Know
7.	Are you aware of the types of disasters or emergencies that are likely to occur in your county of residence?	0	1	88
8.	Do you know what the outdoor warning sirens denote in your county of residence?	0	1	88
9.	Have you signed up to receive emergency alert notifications from your county of residence?	0	1	88
10.	Do you encourage others outside of your household (i.e., friends and neighbors) to be personally prepared for a disaster or emergency?	0	1	88
11.	Are you, or someone in your household, trained in CPR?	0	1	88
12.	Are you, or someone in your household, trained in First Aid?	0	1	88
13.	Do you know where to sign-up for free CPR and First Aid training?	0	1	88

PERCEIVED THREATS

	Strongly Disagree			Neutral			Strongly Agree
I am at risk for experiencing a disaster or emergency.	1	2	3	4	5	6	7
A potential disaster or emergency is likely to be serious.	1	2	3	4	5	6	7
Assembling an emergency kit will mitigate the harmful effects of a disaster or emergency.	1	2	3	4	5	6	7
Having a written, emergency plan that includes instructions for household members about where to go and what to do will mitigate the harmful effects of a disaster or emergency.	1	2	3	4	5	6	7
I am easily able to assemble an emergency kit.	1	2	3	4	5	6	7
I am easily able to develop a written, emergency plan that includes instructions for household members about where to go and what to do.	1	2	3	4	5	6	7

49799101

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