FY16Q3 Instruments

Form Approved

OMB No. 0920-1036

Exp. Date: 12/31/2017

Date: Cluster # Survey # Interviewer initials:

Demographic questions & displacement

D1a. Type of structure:

Single family home

Multiple unit (e.g. duplex, apartment)

Mobile home

Other: _________________

D1b. Is this your primary residence? Yes No Refused

D1c. Do you rent or own this structure?

Rent

Own

Not paying to stay here

Refused

D1d. Is there more than one household living in this structure? Yes No Refused

D2. Are you or any of your regular household members in temporary housing because of the flood?

Yes No Refused

D3. How many people currently staying in your household are

Less than 2 years old? __________

3-5 years old? __________

6-11 years old? __________

11-17 years old? __________

18-64 years old? __________

More than 64 years old? __________

Pregnant? __________

Don’t know

Refused

D4a. Did this dwelling host persons displaced from the flood for any amount of time?

Yes (go to 4b) No (skip to 5) Don’t know Refused

D4b. How many total persons displaced from the flood stayed in your home?

1 2 3 4 5 6 >6 Refused

D4c. Are there persons displaced from the flood still living in your home?

Yes (go to 4d) No (skip to 5) Don’t know Refused

D4d. How many persons displaced from the flood are still living in your home?

1 2 3 4 5 6 >6 Refused

CDC estimates the average public reporting burden for this collection of information as approximately 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 collection of information unless it displays a currently valid OMB control number. Send comments regarding this burden statement or any other aspect of this collection of information, including suggestions for reducing this burden to CDC/ ATSDR Reports Clearance Officer, 1600 Clifton Road, MS D-74, Atlanta, GA 30333, ATTN: PRA (0920-1036).

D5a. Do you have pets?

Yes (go to 5b)

No (skip to 6)

Refused (skip to 6)

Lost pet due to the flood (skip to 6)

D5b. Were you able to care for your pet during and after the flood? Yes No Refused

D6. Was your home damaged or destroyed during the flooding?

Yes, damaged (go to 7)

Yes, destroyed (go to 7)

No (skip to 8)

Refused (skip to 8)

D7a. How would you describe the closeness to a town where your damaged or destroyed home was located?

In town

Outside of town

Don’t know

Refused

D7b. In what county and town (if applicable) was your home? __________________Co, ____________________

D7c. Are you planning to repair or rebuild? Yes No Don’t know Refused

Preparedness

P8a. Did you have advance warning of rising water? Yes (go to 9b) No (skip to 10) Refused

P8b. If you had advance warning, by what method were you notified (check all that apply)?

Television

Radio

Social media

Phone call/text message

Emergency siren/public announcement system

Mobile automated alert

Word of mouth

Other ____________________

P9a. Did you evacuate your home any time during or before the flood?

Yes (go to 9b) No (skip to 9e) Refused

P9b. By what method were you evacuate (check all that apply)?

Traveled with or helped by family/friend/neighbor

Traveled with or helped by a stranger

Rescued by law enforcement

Rescued by emergency personnel

Other ____________________

Refused

P9c. To where did you evacuate (check all that apply)?

Shelter

Hotel

Family/friend dwelling

Higher terrain (unsheltered)

Vehicle

Other ____________________

Refused

P9d. What date did you return home to sleep? ____________

Have not slept in my home since (skip to 10)

P9e. Did any of the following reasons prevent you from evacuating?

Not enough warning

No place to go

Lack of transportation

Caring for person who could not evacuate

Stayed with pet

Stayed for fear of looting/vandalism

Other ____________________

None of these (I evacuated)

Don’t know

Refused

P10a. Did your household have an evacuation plan before the flooding?

Yes No Don’t know Refused

P10b. Did anyone in your house need help evacuating (transportation, medical needs, etc.)?

Yes No Don’t know Refused

P10c. Rank the following from 1 to 5 (1 being your first choice) where you would prefer to evacuate?

__Shelter

__Hotel

__Family/Friend

__Pet-friendly shelter

__Other ____________________

Refused

P11a. Did your household have access to enough food and water for at least 3 days after the flood?

Yes (skip to 12) No (go to 11b) Refused

P11b. Did your household have enough food and water for three days in your primary residence, but could not access it due to flood damage or evacuation?

Yes No Don’t know Refused

P12a. Before the flood, were you aware of the tetanus shot status of most members of your household?

Yes No Don’t know Refused

P12b. Since the flood, are you more aware of the tetanus shot status of most members of your household?

Yes No Don’t know Refused

Healthcare Impact

H13a. During the flood or during cleanup, have you or anyone in your household been injured?

Yes (go to 13b) No (skip to 14) Don’t know Refused

H13b. What part of the body was injured (check all that apply)?

Head

Eye

Neck

Arm/hand/finger

Torso

Back

Leg/foot/toe

Broken bones

Broken skin (burns, cuts, abrasions, puncture wounds, etc.)*

Other ____________________

Don’t know

Refused

H13c. Did you seek care for these injuries?

Yes No Don’t know Refused

H13d. *(Only ask if skin injuries were selected) Did broken skin come in contact with flood waters at any time?

Yes (go to 13e) No (skip to 16) Don’t know Refused

H13e. *(Only ask if skin injuries were selected) Since the flood, did each injured person receive a tetanus shot?

Yes No Don’t know Refused

H14a. Since the flood, has anyone in your household experienced worsening chronic illness (asthma/COPD, diabetes, hypertension, disability, etc.)? Yes (go to 14b) No (skip to 15) Don’t know Refused

H14b. What type of chronic illness(es) worsened? ____________________

H15c. How many persons in your household have had worsening chronic illness(es)? ___________________

H15d. In what repair activities did persons with worsened chronic illness participate? ____________________

H16a. Since the flood, has it been more difficult to get needed medical care for everyone in your household?

Yes (go to 16b) No (skip to 17) Don’t know Refused

H16b. If yes, why (check all that apply)?

Clinic/physician closed

No transportation

Money/cost or insurance problems

Road blocked or bridge out

Other ___________________

Don’t know Refused

H17a. Since the flood, has it been more difficult to get needed prescription medications for everyone in your household?

Yes (go to 17b) No (skip to 18) Don’t know Refused

H17b. If yes, why (check all that apply)?

Clinic/physician closed

Pharmacy closed

No transportation

Money/cost or insurance problems

Road blocked or bridge out

Other ___________________

Don’t know Refused

H18a. Compared to this time last year, have you or anyone in your household noticed an increase in mosquitos around you dwelling?

Yes No Don’t know Refused

H18b. Are you or members of you household doing anything to protect yourselves from mosquitos?

Yes No Don’t know Refused

H19a. Have you or anyone in your household experienced any other new health effects from the flood?

Yes (go to 19b) No (skip to 20) Don’t know Refused

H19b. What are other new health effects experienced since the flood? ____________________________________

Communication/Information Sources

C20. Since the flood, has your household received any “boil water” notices about water sources?

Yes No Don’t know Refused

C21. Since the flood, has your household received any of the following health-related or safety notices?

Carbon monoxide poisoning

Chain saw safety

Heat injury

Mold exposure

Recreational water

Tetanus exposure and prevention

Other ___________________

Don’t know

Refused

C22. Since the flood, has your household received any cleanup tips or information about recovery efforts?

Yes No Don’t know Refused

C23. Since the flood, by what method is your household getting information about health notices, safety, cleanup tips, and recovery efforts (check all that apply)?

Television

Radio

Internet sites

Social media

Text messages

Text messages/phone app

Word of mouth

Flyer/poster

Newspaper

Other ___________________

Don’t know

I have not received any information

Refused

C24. Which is your top preferred method for getting information about health notices, safety, cleanup tips, and recovery efforts?

Television

Radio

Internet sites

Social media

Text messages/phone app

Word of mouth

Flyer/poster

Newspaper

Other ___________________

Don’t know

Refused

C25. Since the flood, from which of these sources did you get information about health notices, safety, cleanup tips, and recovery efforts (check all that apply)?

American Red Cross

Government agency (such as FEMA or the National Guard)

Local health clinic or hospital

Public health department

Disaster resource center

Other ___________________

Don’t know

Refused

Recovery Assessment

R26. Before the flood, which of the following services did you have access to in your home?

Running water (if checked) How many weeks did you go without? ____________

Electricity (if checked) How many weeks did you go without? ____________

Garbage pick-up (if checked) How many weeks did you go without? ____________

Sewer service (if checked) How many weeks did you go without? ____________

Any telephone service (if checked) How many weeks did you go without? ____________

Any internet service (if checked) How many weeks did you go without? ____________

Other ___________________ (if checked) How many weeks did you go without? ____________

Don’t know

Refused

R27a. Before the flood, what was your household’s primary source of drinking water?

Public/municipal

Bottled

Well*

Don’t know

Refused

R27b. Right now, what is your household’s primary source of drinking water?

Public/municipal

Bottled

Well*

Don’t know

Refused

R27c. *(Only ask if using well water for drinking) Did your well flood?

Yes (go to 27d) No (skip to 28) Don’t know Refused

R27d. *(Only ask if using well water for drinking) Did you treat your well to make the water fit for drinking?

Yes, now drinking the well water

Yes, but not yet drinking the well water

No, now drinking the well water

No, not yet drinking the well water

Don’t know

Refused

R28a. Since the flood, has your household used a generator?

Yes (go to 28b) No (skip to 29) Don’t know Refused

R28b. Where is the generator located?

Inside the home

Garage

Outside home and garage <25 feet

Outside home and garage >25 feet

Don’t know

Refused

R29. Since the flood, has your household used a charcoal grill indoors?

Yes, with closed windows

Yes, with open windows

No

Don’t know

Refused

R30. Since the flood, has your household used a gasoline-powered pressure washer indoors?

Yes, with closed windows

Yes, with open windows

No

Don’t know

Refused

R31. Is there currently a functional carbon monoxide detector in your home? Yes No Don’t know Refused

R32. Do you see mold or smell a musty odor in your home? Yes No Don’t know Refused

R33. What stage of flood recovery process is your household in now?

Home uninhabitable—not living at home

Cleaning up—not living at home

Living in the home (still cleaning up)

Living in the home (clean-up finished)

Living in the home (not affected by the flood)

Other ___________________

Don’t know

Refused

Individual questions

N34. What is your age? ______ Refused

N35. What is your sex? M F Refused

N36. Are you Hispanic or Latino? Yes No Don’t know Refused

N37. What is your race?

American Indian/Alaskan Native

Asian

Black or African American

Native Hawaiian or other Pacific Islander

White

Refused

N38. What is your education level?

No high school

Some high school

High school degree

Some college or trade school

Associate degree

College degree

Some graduate school

Graduate degree

Refused

N39. What is your household annual income range?

Less than $5,000

$5,000–$9,999

$10,000–$14,999

$15,000–$19,999

$20,000–$24,999

$25,000–$29,999

$30,000–$34,999

$35,000–$39,999

$40,000–$44,999

$45,000–$49,999

$50,000–$54,999

$55,000–$59,999

$60,000–$64,999

$65,000–$69,999

$70,000–$74,999

$75,000–$79,999

$80,000–$84,999

$85,000–$89,999

$90,000–$94,999

$95,000–$99,999

$100,000–$104,999

$105,000–$109,999

$110,000–$114,999

$115,000–$119,999

$120,000–$124,999

$125,000–$129,999

$130,000–$134,999

$135,000–$139,999

$140,000–$144,999

$145,000–$149,999

$150,000–$154,999

$155,000–$159,999

$160,000–$164,999

$165,000–$169,999

$170,000–$174,999

$175,000–$179,999

$180,000–$184,999

$185,000–$189,999

$190,000–$194,999

$195,000–$199,999

$200,000 and over

Don’t know

Refused

Behavioral health questions

(Read aloud the following before beginning this section)

After disasters, there are many stressors; the following questions ask about your current status.

BN1. Since the flood, do you feel your health has been

Better?

About the same?

Worse?

Don’t know

Refused

BN2. Now thinking about your physical health, which includes physical and injury, for how many days during the past 30 days was your physical health not good?

Number _ _

Don’t know

Refused

BN3. Now thinking about your mental health, which includes stress, depression, and problems with emotions, for how many days during the past 30 days (since the flood) was your mental health not good?

Number _ _

Don’t know

Refused

BN4. During the past 30 days, for about how many days did poor physical or mental health keep you from doing your usual activities, such as self-care, work, or recreation?

Number _ _

Don’t know

Refused

BH5. Since the flood, have you or a member of your household increased the use of

Cigarettes, e-cigs, chewing tobacco Yes No N/A Refused

Alcohol Yes No N/A Refused

Marijuana Yes No N/A Refused

Other illicit drugs Yes No N/A Refused

Prescription/OTC drugs not as directed or not their own Yes No N/A Refused

BH6. Since the flood, has anyone in your household experienced any of the following more than usual (check all that apply)?

Trouble concentrating

Aggressiveness

Problems sleeping

Decreased appetite

Depressed mood

Emotional outbursts

Anxiety/stress

None N/A

Don’t know

Refused

BH7. Since the flood, has anyone in your household received help from a counselor, pastor/clergy member, therapist, or case/social worker for mental health concerns?

Yes

No, but need help

No, did not need help

N/A

Don’t know

Refused

BH8. Since the flood, if you or anyone in your household has had difficulty in seeking services for mental health concerns, what are those reasons (check all that apply)?

Need someone who speaks my language

Hard time trusting in healthcare system or providers

Goes against beliefs

Not aware of resources

Disabled/homebound

Too expensive

No health insurance

No transportation

No child care

No need for services

Worried what others will think

Other ___________________

No difficulties

Don’t know

Refused

Community-specific question section (will be provided from focus groups)

(Examples)

E1. Which of the following services did you receive?

Health services

Pet lodging

National Guard

Other ___________________

E2. Do you still have a problem with flood debris pick-up? Yes No Don’t know Refused

E3. Is there anyone in your household who currently needs the following (check all that apply)?

Oxygen

Dialysis

Home health care

Functional adaptive equipment (wheel chair, ramp, service animal, etc.)

Other ___________________

Don’t know

Refused

E4. What is your greatest need now?

E5. What should your community be doing now to help it recover from the flood?

Form Approved

OMB No. 0920-1036

Exp. Date: 12/31/2017

Community Assessment for Public Health Emergency Response after West Virginia Flood, June 22 – 29, 2016

Confidential Referral Form

Date: ___/__/____ Time: ___:__

Cluster No.: ____

Survey No.: _____

Interviewer’s Initials: _____

Name: _________________________________________________

Address: _______________________________________________

Home telephone: ______ - _____ - _______

Cell phone: _____ - ____ - _______

Summary of Need:

Referral Made: Yes No

Referred to: _______________________________________

CDC estimates the average public reporting burden for this collection of information as approximately 5 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 collection of information unless it displays a currently valid OMB control number. Send comments regarding this burden statement or any other aspect of this collection of information, including suggestions for reducing this burden to CDC/ ATSDR Reports Clearance Officer, 1600 Clifton Road, MS D-74, Atlanta, GA 30333, ATTN: PRA (0920-1036).