Questionnaire - Drought Community Assessment for Public

Form Approved

OMB No. 0920-1036

Exp. Date 12/31/2017

Drought Community Assessment for Public Health Emergency Response -- 2016

Date: ____/______/2016 Cluster No.: _____________ Interview No.: _________________ Interviewers initials: ________ Demographics
Q1. Type of structure: □ Single family □ Multiple unit □ Mobile home □ Other __________		Q3. Including yourself, how many people live in your HH? ___#___
		Q4. Including yourself, how many people living in your HH are Less than 2 years old? __#__ 2-17 years? __#__ 18-64 years? __#__ 65+ years? __#__ □ DK □ Ref
Q2. Does your HH own or rent your place of residence □Own □ Rent □ Other _________________ □ DK □ Ref
Communications
Q5. What is your HH’s primary source of information about the drought? (check ONE) □ Newspaper □ TV □ Friends □ Family members □ AM/FM radio □ Work □ Internet □ Place of worship □ Other, _______________ □ None □ DK □ Ref		Q7. What is the main language spoken in your HH? □ English □ Spanish □ Other____________ □ DK □ Ref
		Q8. Does anyone in your HH have any of the following that could be barriers to effective communication during an emergency? (CATA) □ Impaired hearing □ Impaired vision □ Developmental/cognitive disability □ Difficulty understanding written material □ Difficulty understanding English □ None □ DK □ Ref
Q6. What is your HH most preferred method for receiving information about an emergency event? (check ONE) □ TV □ Radio □ Text message □ Cell phone call □ Landline □ Internet □ NIXLE □ Word of mouth □ Other ___________________________ □ DK □ Ref
Water Sources
Q8. Where did you HH water come from before the drought? (CATA) □ Town, city, or county water system □ Small water system □ Bottled water □ Private well (go to Q8a) □ Cistern □ Surface water (river, lake, spring) □ Other _______________________ □ DK □ Ref Q8a. If well, in the last year, has your HH seen a decrease in water production? □ Yes (go to Q8b) □ No □ DK □ Ref Q8b. If yes, has your HH participated in the Mariposa County’s Dry Well program? □ Yes □ No □ Unaware of program □ DK □ Ref		Q10. Does your HH currently have reliable running water from a well or water system? □ Yes □ No (go to 10a) □ DK □ Ref
		Q11. Does your HH use tap water for drinking and/or cooking? □ Yes, drinking only □ Yes, cooking only □ Yes, drinking and cooking □ No □ NA, currently no running water (go to Q11a) □ DK □ Ref Q11a. What is the main barrier to getting running water in your home? (check one) □ Too expensive □ Well drillers are not available □ Landlord needs to and has not □ Waiting for govt financial help □ Waiting for govt to provide goods or services □ Other ________________________ □ None/NA □ DK □ Ref
Q9. During the current drought, where does your HH water come from? (CATA) □ Town, city, or county water system □ Small water system □ Bottled water □ Private well □ Cistern □ Surface water (river, lake, spring) □ Other _______________________ □ DK □ Ref
		Q12. Is your HH aware of any problems with the quality of your tap water? □ Yes □ No □ Does not use tap water □ DK □ Ref
		Q13. Has your HH noticed a change in the color, clarity, odor, or taste of your water? (CATA) □ Color □ Clarity □ Odor □Taste □ None □ DK □ Ref
Drought Mitigation/Assistance Behavior
Q15. In response to water shortages, have you or members of your HH Reduce water usage □ Yes □ No □ NA □ DK □ Ref Created system to capture/reuse water □ Yes □ No □ NA □ DK □ Ref Installed faucet aerators □ Yes □ No □ NA □ DK □ Ref Repaired plumbing leaks □ Yes □ No □ NA □ DK □ Ref Replaced appliances (washing machine) □ Yes □ No □ NA □ DK □ Ref Decreased washing HH laundry □ Yes □ No □ NA □ DK □ Ref Reduced how often HH flushes toilet □ Yes □ No □ NA □ DK □ Ref Reduced water use for lawn/landscaping □ Yes □ No □ NA □ DK □ Ref Used your swamp cooler less □ Yes □ No □ NA □ DK □ Ref Stopped gardening □ Yes □ No □ NA □ DK □ Ref Quit farming or let land go fallow □ Yes □ No □ NA □ DK □ Ref Shortened shower/bathing times □ Yes □ No □ NA □ DK □ Ref Reduced how often shower/bathe □ Yes □ No □ NA □ DK □ Ref Washed hands less or for shorter time □ Yes □ No □ NA □ DK □ Ref Stopped washing hands with water □ Yes □ No □ NA □ DK □ Ref Washed food less or for shorter time □ Yes □ No □ NA □ DK □ Ref Drank less water □ Yes □ No □ NA □ DK □ Ref Spent less time outdoors □ Yes □ No □ NA □ DK □ Ref Decreased rec. activities that use water □ Yes □ No □ NA □ DK □ Ref			Q17. If the drought continues, would your HH be able to further reduce water consumption? □ Yes (go to 17a) □ No □ DK □ Ref Q17a. If yes, how so? ________________________________
			Q18. Has anyone in your HH looked for assistance related to the drought? □ Yes (go to Q18a) □ No □ NA □ DK □ Ref Q18a. If yes, what type of assistance did your HH need? (CATA) □ Well drilling □ Drinking water □ Health Services □ Utility or energy assistance □ Financial help □ Food assistance □ Employment services □ Other, specify _________________________ □ DK □ Ref Q18b. If yes, Who provided the assistance? (CATA) □ Other family members □ Neighbor □ Employer □ Government agency □ Your faith community □ Food Bank □ Fire, police, emergency agencies □ Utility or water company □ Non-profit organization □ Other ________________________________ □ DK □ Ref Q18c. If yes, How difficult was it to get assistance? □ Very difficult □ Difficult □ Easy □ Very Easy □ DK □ Ref Q18d. What were the barriers to getting assistance? ___________________________­­­_______________________ □ No barriers □ DK □ Ref
Q16. Are there other actions your HH has taken to use less water? ___________________________________________ □ No □ DK □ Ref
Q19. Have your or members of your HH planted drought resistant…(CATA) □ Crops □ Edible Garden □ Landscaping plants □ None □ DK □ Ref
Q20. Are there any dead or dying trees on your property? □ Yes (go to Q20a) □ No □ NA □ DK □ Ref Q20a. If yes, did your HH fell or have the trees felled? □ Yes (go to Q20b) □ No □ NA □ DK □ Ref Q20b. If yes, approximately how much did it cost for your HH to fell or have someone else fell the trees? $_______ □ DK □ Ref Q20c. If yes, approximately how many of each type of tree has your HH felled? □ Oak ____ □ Pine ____ □ Other ____ □ DK □ Ref
Drought Knowledge and Beliefs
California is in the fifth year of drought, I am going to read you a set of statements about drought. Please tell me whether you or your HH members believe the statement to be TRUE (T) or FALSE (F)
Q21. Is there an increased demand for water? □ T □ F □ DK □ Ref	Q25. Some people aren’t cutting water use enough □ T □ F □ DK □ Ref
Q22. There is poor water management by the govt.□ T □ F □ DK □ Ref	Q26. Droughts are caused by lack of rain/snow □ T □ F □ DK □ Ref
Q23. There is overuse of water by cities □ T □ F □ DK □ Ref	Q27. Droughts are caused by climate change □ T □ F □ DK □ Ref
Q24. Too much water is used to protect wildlife □ T □ F □ DK □ Ref	Q28. Droughts are caused by a “higher power” □ T □ F □ DK □ Ref
Health & Behavioral Health Impact of Drought
Q29. Has the drought negatively affected your HH’s… (CATA) □ Property □ Finances □ Health □ Peace of Mind □ Other, _______________________________ □ None □ DK □ Ref		Q36. Has anyone in your HH experienced any of the following more than usual in the last 30 days? Difficulty concentrating □ Yes □ No □ NA □ DK □ Ref Trouble sleeping/nightmares □ Yes □ No □ NA □ DK □ Ref Loss of appetite □ Yes □ No □ NA □ DK □ Ref Racing or pounding heartbeat □ Yes □ No □ NA □ DK □ Ref Agitated behavior □ Yes □ No □ NA □ DK □ Ref Witnessed firsthand violent behavior □ Yes □ No □ NA □ DK □ Ref Thoughts/attempts to harm self □ Yes □ No □ NA □ DK □ Ref Increase alcohol consumption □ Yes □ No □ NA □ DK □ Ref Increased illicit drug use □ Yes □ No □ NA □ DK □ Ref Other _________________________ □ Yes □ No □ NA □ DK □ Ref
Q30. What is the general health of you and members of your HH? □ Excellent □ Very Good □ Good □ Fair □ DK □ Ref
Q31. Is anyone in your HH medically fragile, or been diagnosed with a chronic medical condition? □ Yes □ No □ DK □ Ref
Q32. Does anyone in your HH need any of the following special medical equipment or supplies? (CATA) □ Oxygen □ Dialysis □ Breathing treatment machine □ Ventilator □ Feeding pump □ Insulin □ Other________ □ None □ DK □ Ref Q32a. If yes, since the drought, has anyone in your HH experience any increase in difficulty using or maintaining their equipment or supplies? □ Yes □ No □ NA □ DK □ Ref
		Q37. Did you or anyone in your HH seek help for any of the items we’ve just covered using any of the following services? (CATA) □ Counseling from religious leader or friend □ Emergency room □ Pre-existing support group □ County mental health □ Primary care provider or a clinic □ Social worker or case manager □ Private mental health provider (i.e., psychologist) □ Other, specify _________________________ □ DK □ Ref
Q33. Has the health of you or someone in your HH has worsened because of the drought for the following conditions Asthma □ Yes □ No □ NA □ DK □ Ref COPD □ Yes □ No □ NA □ DK □ Ref Emphysema □ Yes □ No □ NA □ DK □ Ref Hypertension □ Yes □ No □ NA □ DK □ Ref Heart disease □ Yes □ No □ NA □ DK □ Ref Diabetes □ Yes □ No □ NA □ DK □ Ref Psychosocial/mental illness □ Yes □ No □ NA □ DK □ Ref Other ___________­­­­­_________ □ Yes □ No □ NA □ DK □ Ref
		Q38. Did you or a member of your HH have difficulty seeking mental health services? □ Yes (go to Q38a) □ No □ DK □ Ref Q38a. If yes, what are the reasons? (CATA) □ No transportation □ Services too far □ Language barrier □ No child care □ Unable to take time off work □ Not aware of resources □ No health insurance □ Disabled/homebound □ Too expensive □ Don’t trust healthcare system □ Other__________________________________ □ DK □ Ref
Q34. Have you or a HH member sought additional medical attention outside of normal care because of the drought? □ Yes □ No □ DK □ Ref
Q35. Does everyone in your HH currently have health insurance? □ Yes □ No □ DK □ Ref
Other
Q39. Due to the drought, has anyone in your HH Lost employment □ Yes □ No □ NA □ DK □ Ref Had reduced work hours □ Yes □ No □ NA □ DK □ Ref Had to change jobs □ Yes □ No □ NA □ DK □ Ref Traveled further to find work □ Yes □ No □ NA □ DK □ Ref Had decreased income □ Yes □ No □ NA □ DK □ Ref Considered moving □ Yes □ No □ NA □ DK □ Ref Cut size or skip meals because of cost □ Yes □ No □ NA □ DK □ Ref		Q41. Did you or members of your HH hear about this survey prior to us talking to you today? □ Yes □ No □ DK □ Ref Q41a. If yes, How did you or your HH members hear about it? □ Social media □ Press release □ E-mail □ Website □ Family/friends/neighbor □ Other, __________________________ □ DK □ Ref
		Q42. What is your HH greatest need at this time? Thank you!
Q40. “The food that your HH bought just didn’t last, and we didn’t have money to get more” In the last 12 months, was that □ Often True □ Sometimes True □ Never True □ DK □ Ref

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