Form 0920-1154 DISASTER PREPAREDNESS HOME ASSESSMENT SCREENING TOOL --

CDC/ATSDR Formative Research and Tool Development

Attachment G Drexel Disaster Prep Tool -- clean_5.22.20

DREXEL-CYSHCN

OMB: 0920-1154

Document [docx]
Download: docx | pdf

Appendix B
Version Date: 8.14.19


Drexel University Dornsife School of Public Health
Disaster Preparedness Home Assessment Screening Tool

Shape2 Shape1

Form approved

OMB 0920-1154

Exp. 1/31/2023


Study Number___
Date of Assessment ______
Time Started _____
Time Completed ______
Language: English Spanish
Team Members:

SW CHW Medical Equipment Provider
American Red Cross Responder
Initial Visit Follow Up Visit



Please note this tool will be used in electronic format with question-branching logic. For example, we will only ask the caregiver questions related to oxygen if the child is on oxygen.


Section 1 – DIAGNOSTIC DEMOGRAPHICS

In this first section I’ll be asking you some medical information relating to your child’s medical diagnostic and medical needs. For each of the questions below, when I ask about a medical diagnosis, I would like to know if that diagnosis has been made by a medical professional.

  1. Does your child have a developmental disability? Yes No

[If yes] What is your child’s diagnosis (review choices with caregiver)?

    1. Autism spectrum disorder Yes No

    2. Intellectual disability Yes No

    3. Learning disability Yes No

    4. Communication challenges Yes No

      1. Verbal Yes/No

      2. Uses an assistive communication device yes/no (If yes, which type)

      3. Describe any other challenges with communication_________

    5. Deaf or hard of hearing

    6. Other Yes No: _______________________


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Public reporting burden of this collection of information is estimated to average 3 hours 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 D-74, Atlanta, Georgia 30333; ATTN: PRA (0920-1154).


  1. Does your child have a vision impairment that is not significantly improved by corrective lenses? Yes No

    1. [If yes] Does your child use corrective lenses? Yes No



  1. Does your child have a mental health diagnosis(es)? Yes No
    [If yes] What is your child’s mental health diagnosis (review choices with caregiver)?

    1. Anxiety Yes No

    2. Depression Yes No

    3. Bipolar Yes No

    4. Post-Traumatic Stress Disorder Yes No

    5. Obsessive Compulsive Disorder Yes No

    6. Behavioral Concerns Yes (Describe) ___________ No

    7. ADHD Yes No

    8. Other Yes No: _______________________



  1. I am now going to read through a list of medical conditions. Please let me know if your child has been diagnosed with any of the following:

    1. Cerebral Palsy Yes No

    2. Prematurity with complications Yes No

      1. If yes, gestational age ______

    3. Genetic syndrome Yes No
      If yes, is the syndrome any of the following:

      1. A metabolic condition Yes No

      2. Down syndrome Yes No

      3. Fetal Alcohol Spectrum Disorder Yes No

      4. Other Yes No ________________

    4. Epilepsy or seizures Yes No

    5. Diabetes Yes No

    6. Asthma Yes No

    7. Hemophilia Yes No

    8. Chronic renal disease Yes No

    9. Congenital heart disease or cardiac diagnosis Yes No

    10. Chronic lung disease or malformation Yes No

    11. Hypertension Yes No

    12. Muscular Dystrophy Yes No

    13. Spina Bifida Yes No

    14. Sickle Cell Disease Yes No

    15. Other Yes No: _______________________


  1. What do you consider your child’s primary, or most significant diagnosis (populate if more than one is identified)? ______________

    1. Would you agree that this is also the most important, or challenging, diagnosis to consider in an emergency situation? If not, what diagnosis would be most challenging in an emergency? ____________________



  1. Is your child able to walk without any assistance? Yes No

    1. [If no] Is your child able to walk with assistance?
      Yes       Please tell me what equipment your child uses to help him/her walk [ask i-viii]?

No [skip to B]
[If yes] Wheelchair for longer distances Yes No

      1. Walker Yes No

      2. Gait trainer Yes No

      3. Assistive hand devices Yes No

      4. Bracing arms or hand splints Yes No

      5. Bracing Legs (MAFOs, AFOS) Yes No

      6. Stander Yes No

      7. Other Yes No ______________________



    1. [If no] Does your child use a wheelchair or does your child use a stretcher for support?

      1. Wheelchair

      2. Uses stretcher for support

      3. Other Yes No ______________________



  1. Does your child have any special dietary needs?

      1. Yes, Explain: ______________________

      2. No



  1. Is your child on special formula?

      1. Yes, list formula: ______________________

      2. No

  2. Does your child require diapers for urine or stool? Yes No
    If yes, check below

      1. Urinary Yes No

      2. Stool or Fecal Yes No

      3. If yes, do you have a 7 day emergency supply of diapers? Yes No


  3. Does your child take any medication every day, or as needed, such as when they are sick or in an emergency? Yes (answer below) No

    1. Can you list those medications for me?_________________________

      1. Medication name # 1 (check one below) Continue to populate for all medications

        1. Chronic Medication (everyday)

        2. As needed, or emergency medication (when sick)_________________________

    2. How many medications (oral) ___________________

    3. How many medications (injected or other admin) _____________

    4. Do you have a 7-day emergency supply of medicine available? Yes No

      1. If no, why not? (check one)

        1. Not allowable by manufacturer

        2. Not covered by insurance

        3. Other_________________________

    5. Do any of your child’s regular medications require refrigeration? Yes No

    6. Do you regularly check expiration dates on medication? Yes No



  1. Does the caregiver (s) have any special needs (such as a wheelchair, walker, oxygen tank, or vision or hearing impairment) that may make it difficult to ensure the family is safe in the event of an emergency?

    • Yes, please list specific needs: ______________

    • No



SECTION 2-EQUIPMENT/ASSISTIVE TECHNOLOGY REQUIREMENTS

In this next section I’ll be asking you about medical equipment or medical supplies that your child may need.

1. Does your child use any medical equipment or require any medical supplies?
Yes- OK, does your child have a…[ask about all potential equipment listed below]

No

    1. Gastrostomy tube (GT) (also called a mickey or button) Yes No

      1. Do you have an extra g-tube (or button) to replace the g-tube? Yes No

    2. Gastrojejunostomy tube (GJ) Yes No

      1. Do you have an extra g-tube (or button) to replace the g-tube? Yes No

    3. Nasogastric (NG) tube Yes No

      1. Do you have at least 1-2 extra feeding tubes? Yes No

    4. Nasojejunostomy (NJ) tube Yes No

[If yes to a, b, c or d above- populate below questions]

    1. Does your child use a feeding pump? Yes No
      If yes:

      1. Do you know how to convert tube feedings from the pump to gravity feeds?
        Yes No

      2. Do you have extra (7-day supply) of formula, in addition to your regular supply to feed via bolus? Yes No

      3. Do you have syringes (7-day supply) in case of a power outage (to be used in place of the pump)? Yes No

    2. Do you have extra (7-day supply) gravity (feeding) bags? Yes No

    3. Do you have difficulty getting the formula you need for your child? Yes No

    4. Do you have extra extension sets? Yes No

    5. Does the family understand how to use the equipment (DME Assessment)?
      Yes
      No: If no-instruction provided       Yes No

  1. [If yes to a, b or c above- populate below questions] Do you keep (or bring with you) the following in your travel bag? (review all items below with caregiver)

    1. Feeding pump with power cord? Yes No [populate if yes to d above]

    2. Extra g-tube kit? Yes No [populate for a and b]

    3. Ph paper to verify tube placement? Yes No [populate for c above]

    4. Spare feeding tube of correct size? Yes No [populate for c above]

    5. Extension set? Yes No

    6. Feeding bags? Yes No

    7. Syringes (for feeding and any medication)? Yes No

    8. Farrell bags? Yes No N/A

    9. Extra formula? Yes No

    10. Medications? Yes No

    11. Tape/tegaderm? Yes No [populate for c above]

    12. Gloves? Yes No

    13. Active copy of medication and feeding orders? Yes No

  2. Does your child require oxygen? Yes No
    [If yes, medical equipment provider to work with caregiver and complete below items related to oxygen]

    1. Do you have full backup oxygen tanks
      Yes, how many? _______
      No

    2. Is the key attached to oxygen tank? Yes No

    3. Do you have a backup key? Yes No

    4. Do you have a backup regulator? Yes No

    5. Do you have a portable concentrator? Yes No

    6. Do you have a backup nasal canula? Yes No

    7. Type of Oxygen: [Equipment provider to inspect and complete] Via:____________________________

      1. Prescribed Rate: ______ (LPM) Actual _______ (LPM)

      2. Prescribed Patient Usage: ____________(Hours/Day) Actual Patient Usage: ________________ (Hours/Day)

      3. RT Informed of discrepancies  Yes  No

      4. Model/Manufacturer: ____________________________________ Serial#:________________Asset#:__________

      5. Hours_________ Analyzed Fi02: _____% Flow____/____

      6. Within manufacturer limits Yes No

Switched out

      1. Alarms working (Sensor/Power) Yes No Switched out

      2. Filters Clean (Air inlet/Bacteria) Yes No Changed Re-instructed

      3. Back-up cylinder full Yes No Changed Re-instructed

      4. Cylinders stored safely Yes No Moved Re-instructed

      5. Equipment Tagged/Clean Yes No Changed Re-instructed

      6. Oxygen in use sign displayed Yes No Replaced Re-instructed

      7. Do any household members smoke? Yes No

        1. If yes, do they smoke inside the home?

Yes No If no, Reported to RT Re-instructed

      1. Family understands, can use all oxygen-related equipment

        1. If no-instruction provided Yes No


  1. Does your child have a tracheostomy? Yes No
    If yes, do you have the following items available and ready to go in a travel bag? [read all items below]


    1. Backup tracheostomy? Yes No

    2. Down size tracheostomy of appropriate size? Yes No

    3. Back up tracheostomy ties (ties prepared on the backup trach)? Yes No

    4. Portable suction machine with power cord? Yes No

    5. Extra batteries for suction machine? Yes No

    6. Suction canister with all connecting hoses Yes No

    7. Nasal aspirator? Yes No

    8. Appropriate sized suction catheters? Yes No

    9. All tubing and HMV if needed Yes No

    10. 10 saline bullets Yes No

    11. Syringe to inflate cuff, if needed Yes No

    12. Surgilube Yes No

    13. Pulse ox monitor with extra probes Yes No

    14. Ambu bag Yes No

    15. Nebulizer with circuit and tubing power cord Yes No

    16. Rescue inhalers, or nebulized airway medications with adaptor for trach Yes No

    17. Oxygen if appropriate with adaptor and tubing for trach Yes No

    18. Scissors Yes No

    19. Gloves Yes No

    20. Copy of care plan, active medications

    21. Family understands, can use equipment Yes No

      1. If no – instruction provided Yes No



  1. Does your child require mechanical ventilation? Yes No

    1. Do you keep the primary ventilator plugged in, or fully charged when not in use?
      Yes No

    2. Do you have a backup ventilator? Yes No

    3. Do you keep the backup ventilator plugged in or fully charged when not in use?
      Yes No

    4. Are marine/lithium batteries available in case of long-term power outage? Yes No

    5. Is a copy of your child’s ventilator settings in the above go-bag? Yes No

    6. Does the family understand and able to use ventilator-related equipment Yes No

    7. If no – instruction provided Yes No



  1. Does your child have a pulse oximetry machine? Yes No

    1. Is the pulse oximetry machine portable? Yes No

    2. Do you have backup batteries in your home for the pulse ox machine?
      Yes No

    3. Do you have backup pulse ox probes Yes No

    4. Does the family understand and know how to use the pulse ox? Yes No

    5. If no – instruction provided Yes No


  2. Does your child use a CPAP, BiPAP or AVAPs machine? Yes (check 1 below) No

    1. CPAP Machine 

    2. BiPAP machine 

    3. AVAPs machine 

    4. Do you receive a mask and tubing once every 3 months? Yes No [populate for a -c above]

    5. Do you have a contingency plan from your child’s pulmonologist if the power where to go out and your child could not use the CPAP for one or more days? [populate for a or b above] Yes No

    6. Do you keep the machine plugged in with backup batteries in case of a power outage? [populate for c above] Yes No

    7. Do you have a copy of the physician orders for use? Yes No



  1. Does your child have an apnea monitor? Yes, what type? __________ No

    1. Do you have enough (approx. 10-15) leads? Yes No

    2. Do you have a belt? Yes No

    3. Does the family understand and know how to use the equipment? Yes No

    4. If no – instruction provided Yes No



  1. Does your child have a cardiac monitor? Yes List type: _____________ No

    1. Does the family understand and know how to use the equipment?Yes No

    2. If no – instruction provided Yes No



  1. Does your child have a pacemaker? Yes No

    1. Does the family understand and know how to use the equipment?Yes No

    2. If no – instruction provided Yes No



  1. Does your child use a urinary catheter?
    Yes (check all that apply)
    No

    1. Does your child get catheterized every 2-4 hours (intermittently)? Yes No

    2. Does your child use a foley catheter? Yes No
      Do you have the following (read all below) [Populate for a]

        1. Extra catheters (you should receive 150-180 per month) Yes No

        2. 1 tube of lubricant per month Yes No

        3. Bethadyne solution for cleaning if needed Yes No N/A

        4. Gloves Yes No

Do you have the following (read all below) [populate for b]

        1. Extra foleys (you should receive 30/month) Yes No

        2. 5cc syringe, 4 per month Yes No

        3. Urinary drainage bags, 4 bags per month Yes No

        4. Gloves

  1. Does your child have an ostomy? Yes No
    If yes, do you have the following:

    1. Extra ostomy appliances (15-30 per month) Yes No

    2. 10 cc syringe (2 per month) Yes No

    3. 1 box of gauze per month Yes No

    4. Gloves Yes No



  1. Does your child have a central line (picc line or port) for infusion? Yes No

    1. [If yes] Does your child get daily infusions? Yes No

    2. Do you keep your child’s primary pump plugged in? Yes No

    3. Do you have a backup pump programmed? Yes No

    4. Do you keep the backup pump plugged in or fully charged when not in use? Yes No


  1. Does the caregiver have extra diabetic test strips? Yes No [populate only if positive for diabetes]

    1. Does your child use insulin? Yes No

    2. Do you have a backup pump and medicine? Yes No



  1. Does your child have prescribed factor that you keep at home? Yes No [populate only if positive for hemophilia]

    1. If no, what is your safety plan in case of an emergency or trauma? ____________


  2. Does your child have a nebulizer? Yes No

    1. Do you have two extra albuterol pumps available? Yes No

    2. Do you have two extra spacers available? Yes No

    3. Do you have extra nebulizer circuits and masks? Yes No

    4. Do you have an asthma action plan? Yes No

    5. Does the family understand and know how to use the equipment?Yes No

    6. If no – instruction provided Yes No



  1. Does any of the above equipment (if checked) require:

  • Power (to use or to charge) Internet

  • Are flammable materials safely stored?  Yes No 
    [If no] Proper storage procedures reviewed? Yes No



  1. Have you been unable to get the equipment needed to meet your child’s healthcare needs? (nebulizer, feeding pump, CPAP, suction devices are examples)

  • Yes, please explain: __________________________________________

  • No

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[Equipment provider to independently complete]

Primary Equipment Location: ___________Floor ___________Room

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Outlets Marked : XX # of outlets =____

  1. Doorway Marked : DD # of exits = _____

  2. Window Marked : WW # of windows = ______ Bed / Crib Marked: BB
    Other Electronics: _____________________
    Other Appliances: ______________________

Approximate total amps _________________



Secondary Equipment Location: ___________ Floor __________Room



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Outlets Marked : XX # of outlets =____

Doorway Marked : DD # of exits = _____

Window Marked : WW # of windows =
Bed / Crib Marked: BB
Other Electronics: _____________________
Other Appliances: ______________________

Approximate total amps _________________









EQUIPMENT ELECTRICAL REQUIREMENTS (see grid of amps listed)

Acceptable Unacceptable N/A

  1. Amperage    type of service ____ amps

  2. Outlets    total number in use____

  3. Grounding    Total number grounded____

  4. Circuit Breakers
    Labeled    Amps per breaker______

  5. Fuses labeled    Amps per fuse_______

  6. Back-up Procedures
    Reviewed    _____________________







Section 3- DESCRIPTION OF HOUSEHOLD ENVIRONMENT
[Equipment provider to complete with consultation from the caregiver as needed]

  1. Type of Housing Single Family Multi-Family Unit Apartment

  2. Number of floors in the home: Enter Number______

  3. Child/youth with special needs bedroom location (floor of home)

  4. Stairs to bedroom Yes No

  5. Stair glide present (if child non-ambulatory) Yes No

  6. Ramp present outside home (if child non-ambulatory) Yes No

  7. Child bed appropriate for special health care needs
    Yes, List type of specialty bed, if applicable:_________
     No

  8. Is a patient lift needed? Yes No

  9. Heat Yes No
    If yes, Gas     Electric Space Heater Other

  10. Air conditioning Yes No

  11. Fans Yes #___ No

  12. Plumbing Yes No

  13. Wheelchair/Handicap Accessible  Yes  No  N/A

  14. Hazard Free Access to Bathroom/tub/shower  Yes  No  N/A

  15. Structural Limitations  Yes  No(Describe)  N/A

  16. Obstacles to Safe Use/Mobility  Yes(Describe) No  N/A

  17. Allergy Issues: ________________________________________________________

  18. Infestations and/or need for exterminator:___________________________________

  19. Other Problems Identified: ______________________________________________





In this next section we are going to ask you some questions related to fire safety.


  1. Do you have any smoke alarms in your home? Yes No

    1. If yes, do you know the type of smoke alarm(s) in your home? Yes No

      • 9 volt battery alarm

      • 10 volt battery alarm

      • Unsure

  2. Do you have smoke alarms that light up (populate for deaf and hard of hearing residents)?
    Yes No N/A

  3. Do you have a bed shaker alarm (populate for deaf and hard of hearing residents)?
    Yes No N/A

  4. Do you test your smoke alarm once per month? Yes No

  5. How many pre-existing smoke alarms does the household already have? Enter Number___

  6. How many pre-existing smoke alarms are working? Enter Number _

  7. Is there a smoke alarm on every floor of the home including the basement? Yes No

  8. Do you have carbon monoxide detectors in your home? Yes No

  9. Do you test your carbon monoxide detectors once per month? Yes No

  10. Do you have carbon monoxide alarms that light up? (populate for deaf and hard of hearing residents) Yes No

  11. Do you test your carbon monoxide detectors once per month? Yes No

  12. How many pre-existing carbon monoxide detectors does the household already have?
    Enter Number___

  13. How many pre-existing carbon monoxide detectors are working? Enter Number _

  14. Is there a carbon monoxide detector on every floor of the home including the basement? Yes No

  15. Do you have a fire extinguisher(s) within your home or apartment unit, including any common areas? Yes No

    1. If yes, have you been trained on how to use the fire extinguisher? Yes No

    2. If yes, where did you receive the training? _______________

  16. Do you have flashlights in the home? Yes No

  17. Do you check if they are working? Yes No

  18. Are walking paths always free of obstructions, including furniture and equipment, so everyone can safely exit the building during an emergency? Yes No

  19. Is anyone required to travel through a room that can be locked in case of an evacuation or fire? Yes No

  20. Do all interior doors, windows or window bars other than fire doors, readily open from the inside without keys, tools, or
    special knowledge and require less than 5 pounds of force to unlatch and set the door in motion?     Yes No

    1. If a key is required, is the key located near the door or window easily accessible to all residents?
      Yes No

  21. Are any temporary/emergency escape paths clear of obstacles caused by construction or repair?
    Yes No










SECTION 5- EMERGENCY PLANNING

EVACUATION


In this next section, we will be asking you questions about preparing for different types of emergencies or disasters. When answering these questions, please keep in mind your child with special health care needs.

I'm now going to ask you questions about a type of disaster: Picture an emergency that would require you and your family to quickly leave your home to be safe. This could be a severe storm causing flooding or damage that has been predicted for your area, or a house fire. 


[Visual Likert scale used with asking questions]

  1. How likely do you believe an emergency that causes you to evacuate, such as a house fire or flood, will occur in the next 30 days?
    Would you say “1” not likely at all, or “5” extremely likely or a number in between?

Enter Number ___



  1. How likely do you believe an emergency that causes you to evacuate will occur in the next year?
    Would you say “1” not likely at all, or “5” extremely likely or a number in between?

Enter Number ___



  1. If an emergency causing you to evacuate were to occur, how serious do you think the impact would be to your family? Would you say “1” not serious at all, or “5” extremely serious or a number in between? Enter Number ___



  1. How confident are you about your own family’s ability to manage or stay safe in an emergency like this? Would you say “5” extremely confident, “1” Not at all confident, or a number in between? Enter Number___



  1. Have you thought about planning for an emergency that would cause you to evacuate your home? Yes, can you tell me a little more about that? _________________ No


  2. Do you have an evacuation plan to leave your home if it becomes unsafe, due a disaster such as a house fire or flood, for example?
    Yes No

    1. If yes, do all members of the household know the plan? Yes No

    2. Is the evacuation plan practiced within the home?
      Yes

        1. Is the plan practiced and updated or reviewed every 6 months? Yes No

No

    1. Does your evacuation plan include a meeting place identified where all family members know to meet? Yes No

    2. Are healthcare professionals (home nurses, aids, therapists) in the home aware of the evacuation plan (only ask if service providers to come home)?   Yes No N/A


  1. How confident do you feel that having an emergency plan, as described above, will make a positive difference in an emergency? Would you say “5” extremely confident, “1” Not at all confident, or a number in between? Enter Number___



  1. Do you have pets or animals you would need to evacuate with you? Yes No

    1. If yes, do you have an emergency supply of food to last 3 days? Yes No

    2. If yes, is this a service animal or family pet?

      • Service animal

      • Family pet



  1. Does your family have access to transportation to leave home, or a plan for transportation?
    Yes No



  1. Does the family have a place to go if they must leave home? (family, shelter, hospital, other)
    Yes No



  1. Do you know where to go to get information on emergency shelters?
     Yes No



  1. Does the family have a go-bag (sometimes referred to as ER bag) prepared?
    Yes No

    1. If yes, what is in the go-bag? (prompt: medical supplies, medication, important information to grab and go?) List:___________________________


  2. Does your family have a communication plan? (Prompt: a way to contact family members in an emergency, plan to meet up if separated, etc.) Yes No


  3. Have you alerted the local 911 call center about [child’s name] medical needs?

Yes
 No

N/A


  1. Have you registered with a local/state special needs registry?

Yes
 No

N/A


  1. Does the child/youth with special needs have an “About Me” folder/EIF form, or page that briefly explains all the most important medical and/or behavioral/sensory information about your child to someone who may not know him/her? Yes No

    1. If yes, does this include a list of medical professionals involved in your child’s care, name of pharmacy, and contact numbers? Yes No

    2. If yes, where do you keep this document? ____________________


  2. Up-to-date medical care plan summary? Yes No

    1. If yes, where do you keep this? ___________________


  3. Does your child wear a medical alert bracelet? Yes No




SHELTER-IN-PLACE [Visual Likert scale used with asking questions]

Now we would like you to think of a different scenario when answering the next set of questions. Picture an emergency that would require you and your family to have to stay in your home for three or more days without leaving. This could happen due to a severe storm that causes flooding, downed trees, and at least one full day of power loss. This could also be our current situation of an infectious disease outbreak in the region.


  1. How likely do you believe an emergency like this (requiring three or more days at home without leaving) will occur in the next 30 days?

Would you say “5” extremely confident, “1” Not at all confident, or a number in between? Enter Number____


  1. How likely do you believe an emergency like this (requiring three or more days at home without leaving) will occur in the next year?

Would you say “5” extremely confident, “1” Not at all confident, or a number in between? Enter Number____


  1. How serious do you think the impact from an event like this would be on your family?
    Would you say “5” extremely serious, “1” Not serious at all, or a number in between?
    Enter Number___


  1. How confident are you about your family’s ability to stay safe at home during an emergency like this (lasting three or more days)?
    Would you say “5” extremely confident, “1” Not at all confident, or a number in between? Enter Number____



  1. Have you thought about planning for an emergency that causes you to lose power, and your family is unable to leave your home for three or more days? Yes No



  1. Have you tried to learn more or find information about this kind of emergency? Yes No



  1. Does your family have an emergency kit (flashlight, can opener, etc.)? Yes No

    1. [If yes] Have you reviewed or updated your emergency kit in the last 6 months?
       Yes No


  1. Does the family have an emergency supply of ready-to-eat food to last 3 days? Yes No


  2. Does the family have an emergency supply of water? A recommended supply is one gallon per person per day for drinking and sanitation (for at least 3 days)? Yes No


  1. Does your family have a back-up power plan? Yes No

If yes, specify below:
 Generator

        1. If yes, instruction provided for safe use Yes No

      • Invertors

      • Batteries Yes No

      • Other (specify______________________________)


  1. Have you experienced a disaster or emergency with your child before? Yes No
    If yes, please specify     ___________________________________________







SECTION 6- SOCIAL DETERMINANTS OF HEALTH

In this next section we would like to ask you about some of your more basic needs like food and housing. We understand that it can be hard to prepare for a possible disaster when there are things you are worried about or struggling with right now.


  1. Does your family have social or community support (family, church, etc.) to rely on if an emergency were to occur? Yes No If yes, please choose: (check all that apply)

    1. Extended family

    2. Friends

    3. Church or place of worship

    4. Other community support (please list)_________________


  2. Is there someone in your home who doesn’t have health insurance?

    1. Yes

      • If yes, who _________

    2. No


  3. Have you received SSI or Medicaid for your child in the past year?

    1. Yes

      • Are you currently receiving SSI or Medicaid for your child?

        1. Yes

        2. No

          1. Has it been denied in the past 90 days?

            1. Yes

            2. No

    2. No

      • Have you been denied for SSI or Medicaid for your child in the past 90 days?

        1. Yes

        2. No


  4. Have you received Social Security benefits (SSI/SSD) for yourself in the past year?

    1. Yes

      • Are you currently receiving SSI or Medicaid for yourself?

        1. Yes

        2. No

          1. Has it been denied in the past 90 days?

            1. Yes

            2. No

    2. No

      • Have you been denied for SSI or Medicaid for yourself in the past 90 days?

        1. Yes

        2. No

  5. Have you received food stamps, WIC, cash assistance, or Temporary Assistance for Needy Families (TANF) in the past year?

    1. Yes

      • Are you currently receiving food stamps, WIC, cash assistance, or Temporary Assistance for Needy Families (TANF)?

        1. Yes

        2. No

          1. Has it stopped?

            1. Do you know why? If yes, please explain_____________

            2. I don’t know why

    2. No

  6. Within the past 3 months were you worried whether your food would run out before you had money to buy more?

    1. Often

    2. Sometimes

    3. Never


  7. Are you having difficulty with getting the formula you need for your child (Pediasure, etc.)?

    1. Yes

    2. No

    3. N/A


  8. Do you own or rent your home?

    1. Own

      • Do you have homeowners insurance?

    2. Rent

      • Do you have renters insurance?


  9. What is your primary method of transportation when traveling with your child?

    1. Personal/Family vehicle

    2. Public Transit

    3. Walk

    4. Medical Transportation (van, ambulance, paratransit)

      • Ambulance Transport

      • Logisticare

    5. Other __________________


  10. Does your child with special needs live at another residence 1 or more nights per week?

    1. Yes

    2. No


  11. Is there a telephone (landline or cellular) working and available at all times in case of an emergency?

    1. Yes

    2. No


  12. Have you had trouble paying for your utilities (such as gas/water/electric/phone) in the last 12 months?

    1. Yes

      • If yes, what utility bills? _______________

    2. No

    3. Decline


  13. Do you have difficulty getting home repairs (mold, rodents, and leaks)?

    1. Yes

      • If yes, what repairs? _______________

    2. No


  14. Do you have issues in your home with rodent, insects, or other pests? Yes No


  15. Do you have any difficulty making your home more accessible for your child with special needs?

    1. Yes

      • If yes, what modifications have been challenging? ______________________

    2. No

    3. Does not apply


  16. [If you rent] In the past 30 days, has your landlord threatened to evict you or turn off utilities?

    1. Yes

    2. No

    3. Decline


  17. Are you worried about not having a permanent home to stay in or that you might become homeless?

    1. Yes

    2. No

    3. Decline


  18. Are you afraid you might be hurt by a partner or family member?

    1. Yes

    2. No

    3. Decline


  19. Over the past two weeks, how often have you felt down, depressed, or hopeless?

    1. Often

    2. Sometimes

    3. Never

    4. Decline



  1. Does the primary caregiver have a reliable backup caregiver skilled in caring for the child’s specific health care needs?

    1. Yes

      • Who is that person? ______________

    2. No


  2. What is your greatest strength as a caregiver? __________________________


27

Created 12/2018 revised 8/14/19

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