Appx 4 HH Survey SAMPLE

Appx 4 HHSurvey_SAMPLE_March 2_Clean.docx

Assessment of Chemical Exposures (ACE) Investigations - FY2016 Q2 Burden Report

Appx 4 HH Survey SAMPLE

OMB: 0923-0051

Document [docx]
Download: docx | pdf

Shape2

Appendix 4: Household Survey

Shape3

Form Approved

OMB No. 0923-XXXX

Exp. Date XX/XX/20XX

Interviewer__________ Household ID___________

Date _____________ Start time _____________ End time ______________

Cluster/Zone __________ Latitude _______________ Longitude ______________

Type of residence

Shape4 Single family Shape5 Multiple unit Shape6 Mobile home Shape7 Other ________________________

Shape8

HOUSEHOLD SURVEY


Module A: Contact Information


  1. What is your full name? __________________________________________________


  1. What is your street address?


Street Apt


City __ State __ __ Zip Code:


  1. What is the best telephone number to reach you in case we have questions about your survey? Please specify if this is a cellular phone, house phone, or work phone.


( __ __ __ ) __ __ __ ‑ __ __ __ __ Shape11 Cell Shape12 House Shape13 Work

Module B: Demographics


  1. How many people live in this residence? _____


How many are male? _____ How many are female? ­­­­­_____


  1. How many people that live here are less than two years old? _____


217 years old? _____ 1864 years old? _____ More than 64 years old? _____


  1. How many people in this household are of Hispanic, Latino, or Spanish origin? ­­­­_____


  1. To which race do members of this household most identify? I will read a list of races. Please tell me how many people in the household identify as being that race. Record the number of people of each race described:


_____ Black _____ American Indian/Alaska Native

_____ White _____ Native Hawaiian or other Pacific Islander

_____ Asian



Shape14

Public reporting burden of this collection of information is estimated to average 15 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 E-11 Atlanta, Georgia 30333; ATTN: PRA (0923-XXXX)


Module C: Location/Exposure and Communications


  1. Was anyone home at any time between [Incident Date/Time] and [End Date/Time]?

Shape15 Yes

Shape16 No


  1. After [the release] did you or anyone else in your household detect any unusual smells or tastes that you think were related to the incident?

Shape17 Yes

Shape18 No


  1. How did your family first receive information or instructions about the incident? Check only one.

Shape19 Noticed odor/saw chemical Shape20 Directly from person in authority (police, firefighter)

Shape21 Reverse 911 call to landline phone Shape22 Reverse 911 call to cell phone

Shape23 Call to landline phone Shape24 Call to cell phone

Shape25 TV Shape26 Radio

Shape27 Text message on a cell phone Shape28 Social media (Facebook, Twitter)

Shape29 Directly from another person (such as friend or relative)

Shape30 Other (Please specify):______________________________________________________



  1. As the incident progressed, how did you obtain information? Check all that apply.

Shape31 Directly from person in authority (police, firefighter)

Shape32 Reverse 911 call to landline phone Shape33 Reverse 911 call to cell phone

Shape34 Call to landline phone Shape35 Call to cell phone

Shape36 TV Shape37 Radio

Shape38 Text message on a cell phone Shape39 Social media

Shape40 Website Shape41 Community meeting

Shape42 Newspaper

Shape43 Directly from another person (such as friend or relative)

Shape44 Other (Please specify):______________________________________________________


  1. Did your household receive instructions to shelter in place (meaning stay inside with the doors and windows closed) after [the release]?

Shape45 Yes

Shape46

Shape47 No Go to Question C7

  1. How did you receive instructions to shelter in place?


______________________________________________________________________


  1. Were you given specific instructions about how to shelter in place?

Shape48 Yes

Shape49 No


  1. What actions, if any, did you take to shelter in place?


______________________________________________________________________

______________________________________________________________________


  1. Did your household evacuate after [the release]?


Shape50 Yes

Shape51

Shape52 No Go to Question C13


  1. Which day and at approximately what time did you evacuate?


____/____/______ ____:_____ Shape53 AM Shape54 PM

MM DD YYYY


  1. When you evacuated, where did you go?


Shape55 Shelter Shape56 Hotel Shape57 Friend’s/family’s house Shape58 Other _________________________


  1. When did you return home? ____/____/______ ____:_____ Shape59 AM Shape60 PM

MM DD YYYY



  1. Do you have any pets?

Shape61

Shape62 Yes Go to Question C15

Shape63 No



  1. What kind of pets do you have and how many are there of each kind?

_____ Dog(s)

_____ Cats(s)

_____ Bird(s)

_____ Fish

_____ Other (specify):______________________________________________________

  1. If you have pets, did you take all of them them with you when you evacuated?

Shape64

Shape65 Yes Go to Question C15

Shape66 No

Shape67

Shape68 Took some but not all Go to Question C14



  1. Which pets did you leave behind when you evacuated and what led to your decision to leave them?

______________________________________________________________________

______________________________________________________________________


Module D: Health Status


  1. Within 24 hours of the incident, did you or anyone in your family have any symptoms of an illness?

Shape69 Yes

Shape70

Shape71 No Go to Question E1



  1. I will now read a list of symptoms that sometimes can follow exposure to [chemical]. Please tell me if anyone in the household who experienced each symptom within 24 hours of the release. Do not include a symptom that someone had before the release unless it got worse after the release. For each symptom that someone experienced, ask: How many people in the household experienced [symptom]?


Eye irritation Shape72 Y Shape73 N Shape74 DK If yes, how many? ________

Nose or throat irritation Shape75 Y Shape76 N Shape77 DK If yes, how many? ________

Coughing Shape78 Y Shape79 N Shape80 DK If yes, how many? ________

Wheezing Shape81 Y Shape82 N Shape83 DK If yes, how many? ________

Difficulty breathing Shape84 Y Shape85 N Shape86 DK If yes, how many? ________

Headache Shape87 Y Shape88 N Shape89 DK If yes, how many? ________

Dizziness or lightheadedness Shape90 Y Shape91 N Shape92 DK If yes, how many? ________

Ringing of the ears Shape93 Y Shape94 N Shape95 DK If yes, how many? ________

Nausea Shape96 Y Shape97 N Shape98 DK If yes, how many? ________

Vomiting Shape99 Y Shape100 N Shape101 DK If yes, how many? ________

Skin itching or burning Shape102 Y Shape103 N Shape104 DK If yes, how many? ________

Skin rash Shape105 Y Shape106 N Shape107 DK If yes, how many? ________



  1. Were there any symptoms I didn’t ask about that members of the household experienced?


Shape108 Yes (Please specify.)

Shape109 No


______________________________________________________________________

______________________________________________________________________


Module E: Medical Care Received


  1. Did you or anyone in your family receive medical care or a medical evaluation because of the incident?

Shape110

Shape111 Yes Go to Question F3

Shape112 No


  1. Ask only if someone had symptoms: Why didn’t you or your family members seek medical care?

Shape113 Symptoms were not bad enough    

Shape114 Don’t like to go to the doctor

Shape115 Didn’t want to take time

Shape116 Worried about who would pay for the medical visit

Shape117 Worried about losing job

Shape118 Other (Please specify): ______________________________________________

Shape119 Unsure


  1. For each person who received medical care, please tell me the person’s name, where they received care, and the date. Please include medical evaluations by emergency medical services or EMTs, hospitals, and doctor’s offices.



Name

Where Received Care

Date




















  1. If a hospital was named, ask: Was [name] treated and released from the emergency department or hospitalized? If hospitalized, ask: How long was [he/she] hospitalized?



Name

Treated and Released

Hospitalized

Duration of Hospitalization























Module F: Needs


  1. As a result of the incident, does your household need any of the following…

Read all choices to the respondent.


Medicines or medical supplies Shape120 Yes Shape121 No

Medical care Shape122 Yes Shape123 No

Water Shape124 Yes Shape125 No

Food Shape126 Yes Shape127 No

Shelter Shape128 Yes Shape129 No

Utilities Shape130 Yes Shape131 No

Anything else Shape132 Yes Shape133 No


If needs are identified in Question F1, obtain details on exactly what is needed.






Module G: Other Information


  1. Is there anything else you want to tell us related to the [chemical] incident?


That completes this survey. I would like to sincerely thank you for your time. Be sure to record the end time on the first page of this survey.


File Typeapplication/vnd.openxmlformats-officedocument.wordprocessingml.document
AuthorRSmartis
File Modified0000-00-00
File Created2021-01-23

© 2024 OMB.report | Privacy Policy