Form 0920-1221 Los Angeles County Community Emergency Preparedness Surv

Who’s at Risk: From Hazards to Communities—An Approach for Operationalizing CDC Guidelines to Determine Risks, and Define, Locate and Reach At-Risk Populations in Public Health Emergencies

Survey-Proposed Change 30MAR2018

Community Emergency Preparedness Survey

OMB: 0920-1221

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ID _ _ -_________

Community Emergency Preparedness Survey


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Form Approved

OMB Control No.: 0920-1221

Expiration Date: 03/31/2020

Today’s Date: ____/____/2018

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Instructions: The information gathered from this survey will be used to understand the needs of community members in the event of an emergency. Please take a moment to fill out this survey. All responses are anonymous and confidential. This survey is voluntary. If you are not interested in participating, please return the blank survey to the survey staff. Thank you for your time.

First, please tell us a little about yourself:

  1. Age: _____

  2. Sex: Female Male

  3. Zip Code of Residence: __________ Homeless

  4. Ethnicity:

Hispanic/Latino Not Hispanic/Latino


  1. Race (Check all that apply):

American Indian or Alaska Native Asian Native Hawaiian or other Pacific Islander

Black or African American White

  1. What best describes your education? (Check only one)

Completed less than high school High School Graduate or GED

Some college, community college or trade school College Graduate/Postgraduate

  1. How would you describe your employment status? (Check all that apply)

Full Time Part Time Self-employed Unemployed Retired Disabled

  1. What type of transportation do you usually use? (Check only one)

Car Bus Train Bike Walk Motorcycle Lyft/Uber Other: __________________

  1. How often do you take public transportation? (Check only one)

Never Rarely Sometimes Often

  1. Do you speak a language other than English at home? (Check only one)

Yes No

  1. If yes, what other language(s) do you speak at home? (For example, Korean, Spanish, etc.):

__________________________________________ Does Not Apply

  1. Are you currently involved with any of the following types of community groups or organizations?

(Check all that apply)

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Please go to the next page

CDC estimates the average public reporting burden for this collection of information as 5 minutes per response, including the time for reviewing instructions, searching existing data/information sources, gathering and maintaining the data/information 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 (0920-1221).

Religious church/congregation Service organization (Elks’, Rotary, etc.) Social service agency Other: _______________________

Now we would like to ask you a few questions about how you get healthcare services in Los Angeles County:

  1. Where do you usually go to receive healthcare services (examinations, medications, etc.)? (Check only one)

Primary Care Doctor’s Office Hospital Emergency Room Urgent Care Health Clinic Public Health Center Prefer not to Answer Other: _______________________

  1. How far do you usually have to travel to reach these healthcare services? (Check only one)

Less than 1 mile Between 1 and 3 miles Between 3 and 5 miles More than 5 miles



Now we would like to ask you some questions about how you might get information during an emergency in your city:

  1. In general, how do you prefer to access the internet? (Check only one)

Home computer (like a laptop or desktop computer)

Cell phone

Tablet

Computer at work

Computer at the library/Public computer

I do not use the internet

  1. In an emergency, how would you anticipate getting news from emergency/government officials?

(Check all that apply)

TV Radio Internet Print News (newspaper) Other__________________ Don’t know

Now we would like to ask you some questions about how you might respond during an emergency (like an earthquake) in your city:

  1. During an emergency, what kind of resource(s) do you think you would need to stay home for 3 days?

(Check all that apply)

Food Water Information Housing Transportation

Prescription Medications Other: _______________________

  1. Would you be able to evacuate your city if asked to by emergency/government officials?

Yes No Yes, if public transportation was provided Don’t know

  1. Would you be able to go to a location in the community to receive life-saving supplies (for example, medications)? (Check only one)

Yes No Don’t know Prefer not to answer

(If No, Don’t Know, or Prefer not to Answer, please skip to question 20.)

  1. How would you travel to that location? (Check only one)

Car Bus Train Bike Walk Motorcycle Lyft/Uber Other: __________________

  1. During an emergency in your city, do you think you or someone in your household would want to speak to a mental health professional? (Check only one)

Yes No Don’t know Prefer not to Answer



  1. In an emergency, could you see yourself going to any of these community-based organizations for help?

(Check all that apply)

Religious church/congregation Service organization (Elks’, Rotary, etc.) Social service agency American Red Cross Other: _______________________


CHECK ONE ANSWER PER QUESTION


Yes

No

I Don’t Know

I Don’t Wish To Share

  1. Have you, or anyone in your household, taken special training for emergencies in your community (CERT, CPR, First Aid, etc.)?

  1. Do you know where the nearest hospital is to your home?

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Thank you for your participation! Please return the survey to the attendant.


Los Angeles County Dept. of Public Health, March 2018

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