Sample Questionnaires

Form Approved

OMB No. 0920-XXXX

Exp. Date xx/xx/20xx

Attachment C. Sample CASPER Questionnaires

Sample Disaster/Recovery CASPER Questionnaire Used in an Actual Event

To be completed by team BEFORE the interview
Q1. Date (MM/DD/YY):	Q4. Team Member Initials:
Q2. Cluster Number:	Q5.Team Number:
Q3. Survey Number:	Q6. County Name:
Demographic Information
Q7. Is this your primary residence? □ Yes □ No □ Refused	Q12. Did you evacuate your home anytime during or before the flood? □ Yes (go to 12c-12e) □ No (go to 12b) □ Refused Q12b. If NO, What prevented you from evacuating? □ No place to go □ No need to evacuate □ Lack of transportation □ Stayed w/pet □ Other _____________________________________ □ DK □ Refused If YES, Q12c. Where did you evacuate to? □ Shelter □ Hotel □ Friend/Family home □ 2nd home □ Other __________________ □ DK □ Refused Q12d. What date did you evacuate? ____/____/ Q12e. What date did you return home to sleep? ____/____/
Q8. How many people live in your household? ____________
Q9. How many people living in your household are Less than 2 years old? _____ 2-17 years old? _____ 18-64 years old? ____ More than 65 years old? _____ □ DK □ Refused
Q10. Do you feel your home is currently structurally safe to live in? □ Yes □ No □ DK □ Refused
Q11. Are you currently in temporary housing? ____________ □ Yes □ No □ DK □ Refused

Public reporting burden of this collection of information is estimated to average 30 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).

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Cleanup, Utilities, and Supplies
Q13. How high did the flood waters reach inside your home? _______________ft □ DK	Q20. What was your primary source of drinking water before the flood? □ Well □ Public/Municipal □ Bottled □ DK □ Refused Q20b. What is your primary source of drinking water right now? □ Well □ Public/Municipal □ Bottled □ DK □ Refused Q20c. If using a well or municipal (tap water), are you treating the water? □ Yes, boiling □ Yes, chemical □ No □ DK □ Refused
Q14. What stage of the flood recovery process are you in now? □ Home uninhabitable—not living at home □ Cleaning up—not living at home □ Cleaning up—living at home □ Living in the home (no cleanup) □ Home never flooded □ Don’t know □ Other: _____________________ □ Refused
Q15. Do you see mold or smell a moldy /musty odor in your home? □ Yes □ No □ DK □ Refused	Q21. Do you have access to adequate food for everyone in your household for the next 3 days? □ Yes □ No □ DK □ Refused
Q16. Is there 10 sq ft or more of water damage and/or mold anywhere inside your home? (10 sq ft is approximately the size of an infant’s playpen) □ Yes □ No □ DK □ Refused	Since the flooding, have you used…. Q22a: A charcoal grill/briquettes indoors? □ Yes, with windows open □ Yes, with windows closed □ No □ DK □ Refused Q22b. A pressure washer with the actual engine in the house? □ Yes, with windows open □ Yes, with windows closed □ No □ DK □ Refused
Q17. Do you currently have the following services in your home? R unning water □ Yes □ No □ DK □ N/H □ Ref Electricity □ Yes □ No □ DK □ N/H □ Ref Garbage pickup □ Yes □ No □ DK □ N/H □ Ref Sewage services □ Yes □ No □ DK □ N/H □ Ref Any Telephone □ Yes □ No □ DK □ N/H □ Ref
Q18. What is your current source of electricity? □ No electricity □ Generator □ Power company □ N/H □ DK □ Refused	Q23. Do you have a carbon monoxide detector? □ Yes □ No □ DK □ Refused Q23b. If YES, is it working? □ Yes □ No □ DK □ Refused
Q19. Since the flooding, have you used a generator? □ Yes □ No □ DK □ Refused Q19b. If YES, where is/was the generator located? □ Inside □ Garage □ Outside, <25 ft □ Outside, ≥25 ft □ DK □ Refused Q19c. If outside, is/was the generator near an open or broken window? □ Yes □ No □ DK □ Refused
	Q24. Since the flooding, have you had any significant loss to your crops? □ Yes, Minor loss □ Yes, Significant loss □ No Loss □ Not Applicable □ DK □ Refused Continue questionnaire on back…
Animal Safety
Q25. Since the flooding, have you noticed an increase in mosquitoes around your home or neighborhood? □ Yes □ No □ DK □ Refused	Q27. Since the flooding, have you or anyone in your household noticed an increase in snakes around your home or neighborhood? □ Yes □ No □ DK □ Refused
Q26. Are you doing anything to protect yourself from mosquitoes? □ Yes □ No □ DK □ Refused Q26b. If YES, what type of protective measures are you using? (check all the apply) □ Wearing repellent □ Eliminating standing water □ Wearing protective clothing (long shirts/pants) □ Other, _______________________________________	Q28. Since the flooding, have you or anyone in your household noticed an increase in alligators around your home or neighborhood? □ Yes □ No □ DK □ Refused
	Q29a. Since the flooding, have you or anyone in your home been bitten by an animal or insect other than mosquitoes? □ Yes □ No □ DK □ Refused Q29b.If yes, what animal_________________________________

Health Status and Access to Care
Q30. Since the flooding, has anybody in your household experienced Cough □ Yes □ No □ DK Fever □ Yes □ No □ DK Nausea/stomach ache/diarrhea □ Yes □ No □ DK Rash □ Yes □ No □ DK Worsening of chronic illness (such as hypertension, asthma or diabetes) □ Yes □ No □ DK If YES, what type(s) of illness(es)? ___________________ Other, _____________________ □ Yes □ No □ DK	Q33. Is there anybody in your household who currently needs □ Oxygen □ Dialysis □ Home health care □ Other type of special care, _________ □ DK □ Refused
	Q34. Since the flooding, Are you able to get the care you need for everyone in your household? □ Yes □ No □ DK □ Refused
	Q35a. Is everybody in your household getting the prescription medications they need? □ Yes □ No □ DK □ Refused Q35b. If NO, why not? (check all that apply) □ Clinic/physician closed □ Pharmacy closed □ No transportation □ Money/cost □ Medicare/Medicaid/insurance problems □ Other, _________________________ □ DK □ Refused
Q31a. Since the flooding, have you or a member of your household been injured in or around your home? □ Yes □ No □ DK □ Refused Q31b. If YES, what part of the body was injured?(check all that apply) □ Head □ Body/torso □ Back □ Neck □ Leg(s) □ DK □ Arm(s) □ Foot/feet □ Refused Q 31c. If YES, were you or the member of your household injured while repairing the residence or retrieving items? □ Yes □ No □ DK □ Refused Q31d. If YES, what caused the injury?_______________________
	Q36. Since the floods, has anybody in your household experienced an increase in Agitated behavior □ Yes □ No □ DK □ Ref Anxiety or stress □ Yes □ No □ DK □ Ref Depressed mood □ Yes □ No □ DK □ Ref Difficulty concentrating □ Yes □ No □ DK □ Ref Loss of appetite □ Yes □ No □ DK □ Ref Trouble sleeping/nightmares □ Yes □ No □ DK □ Ref Increased alcohol/drug use □ Yes □ No □ DK □ Ref Witnessed or experienced violence □ Yes □ No □ DK □ Ref Other, ________________ □ Yes □ No □ DK □ Ref
Q32. Has everybody in your household had a tetanus (DTaP/Tdap/Td) shot in the past 10 years? □ Yes □ No □ DK □ Refused
Communications
Q37a. Since the flooding, have you received any information about boil water advisories in your area? □ Yes □ No □ DK □ Refused Q37b. If YES, what was your PRIMARY source of information? □ TV □ Radio □ Text message □ Neighbor, word of mouth □ Flyer/poster □ Local newspaper □ Internet, ___________ □ Other, ___________________ □ DK □ Refused	Q39a. Have you received any other health advice, clean up tips, or other information related to the flood? □ Yes □ No □ DK □ Refused Q39b. If YES, what was your PRIMARY source of information? □ TV □ Radio □ Text message □ Neighbor, word of mouth □ Flyer/poster □ Local newspaper □ Internet, ___________ □ Other, ___________________ □ DK □ Refused
Q38a. Have you looked for information or answers to questions regarding the flood and its effects? □ Yes □ No □ DK □ Refused Q38b. Where would you look for reliable information regarding the flood and cleaning up after the flood? □ TV □ Radio □ Text message □ Neighbor, word of mouth □ Flyer/poster □ Local newspaper □ Internet, ___________ □ Other, ___________________ □ DK □ Refused	Q40. What is your greatest need at this time? Thank you for your time!

Many of these questions are those that the state requests we collect. They provide valuable situational awareness and information at the household level that can help decision makers take action. For example,

• Vulnerability assessment questions (e.g. Sample Preparedness Questionnaire questions 13, 14, 15, 16) help to assess the social vulnerability of a household and their health status (e.g. resources available to them, SES, and physical and mental health conditions that may result in increased vulnerability to the impacts of the disaster.

• Water damage and mold exposure questions (e.g., Sample Flooding Questionnaire questions 13, 15, 16) can indicate the potential for environmental exposure to mold and give public health officials and decision makers an estimate of how many households might be affected by flooding and how badly damaged homes are. This would also help public health officials know if it was important to put resources towards health messaging around mold.

• Carbon Monoxide (CO) exposure questions (e.g., Sample Flooding Questionnaire questions 19b, 19c, 22a, 22b) provide critical information that can tell public health officials if many people are using/misusing CO producing equipment. Knowing this can help prevent potential morbidity and mortality from CO exposures. This would also help public health official know if it was important to put resources towards health messaging around preventing CO exposure.

• Mental/behavioral health questions (e.g., Sample Flooding Questionnaire question 36 and Sample Preparedness Questionnaire questions 14, 15) provide important information because mental health issues arising from or exacerbated by a disaster can affect a person’s physical health and ability to recover after a disaster. This would also help public health official know if it is important to put resources towards health messaging around mental health and provide community mental health resources.