Survey questionnaire

Availability, Use, and Public Health Impact of Emergency Supply Kits among Disaster-Affected Populations

P_Att1_Survey_PaperBased_20200924 clean

Questionnaire - paper-based

OMB: 0920-1344

⚠️ Notice: This form may be outdated. More recent filings and information on OMB 0920-1344 can be found here:

2022-09-30 - No material or nonsubstantive change to a currently approved collection

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Attachment 1: Paper-Based Questionnaire

INTRODUCTION
Participation is completely voluntary. You may decline altogether or leave blank any questions you do not
wish to answer. The results of this research study may be published in a report that combines all
participants’ data, but the information you provide will not be shared at an individual level. Should you
share any potentially identifying data, such as your name or address, it will be deleted at the end of the
research project.
There are no direct benefits or foreseeable risks of participating in this study. Your answers cannot be used
to affect any disaster-related benefits you might receive now or in the future, and your data will never be
sold.
If you agree to participate, it should take approximately 30 minutes to complete. If you have any questions
about this project, you can call 1-770-488-3422. If you have questions about your rights as a research
participant, please contact CDC's Human Research Protection Office at 1-404-639-7570
Thank you for your assistance in this important endeavor.

INSTRUCTIONS
 This survey should be completed by an adult 18 years of age or older who knows a lot about the
experiences and health of people who lived in this household at the time of the disaster named on the
cover letter.
 Mark your answer by completely filling in the circle.
Yes
No
 Mark an X in boxes when asked to select ALL that apply
Batteries
Flashlight
Radio
 Write numbers and text in capital letters in borders.

1 2 MAIN STREET
 Use a black or blue pen, if available.

START HERE
Many questions in this survey ask about your entire household. Your “household” is all the people,
including children, other adults, and yourself, who live and sleep in your home most of the time.
1.

First, we need to confirm that you should complete this survey. Are you an adult aged 18 years
or older who knows a lot about the experiences and health of people who lived in this household
at the time of the disaster?
Yes
No
Please give this survey to an adult who knows a lot about your household’s experience
and health.

At the time of the disaster, did your household live at the address listed on the cover letter?
Yes, my household lived at this address  Go to Question 4
No, my household lived somewhere else
3.

Please indicate the address where your household lived at the time of the disaster.
Address Line 1:
Address Line 2:
City:
State:
Zip Code:

EVACUATION
Next, we want to know whether any household members evacuated your home because of the
disaster. Evacuation is defined as leaving your home to stay somewhere else for at least one night.
4.

Did any household members evacuate your home because of the disaster?
Yes, all evacuated
Yes, some evacuated
No
 Go to Question 6
5.

Where did household members who evacuated go? Select ALL that apply.
The home of a friend or family member
A shelter set up by organizations like the Red Cross or churches
A hotel
A second home
Vehicle or recreation vehicle (RV)
Other, please specify:

Why did household members stay at home? Select ALL that apply.
Not applicable, no one stayed at home
Did not feel it was necessary to leave
Did not have family or friends to stay with
Did not know where else to go
Did not want to leave pets
Did not feel that it is safe to go to a shelter
Concern about the cost of evacuating, such as gas, food, and lodging
Evacuation was difficult because of disability or health issue
Stayed home during previous disasters with no problem
Had a bad experience during previous evacuation
Other, please specify:

Were any of your household members out of town at the time of the disaster?
No, all household members were in town
Yes, some household members were out of town
Yes, all household members were out of town  STOP. Please place the survey in the return
envelope and mail it back to us.

HOUSEHOLD TYPE
8.

What best describes the type of home your household lived in at the time of the disaster?
Mobile or manufactured home
Single-family house
Attached duplex or townhome
Low-rise apartment building (1-6 stories or less)
High-rise apartment building (7 or more stories)

Is that home…?
Owned by you or someone in your household
Rented
Occupied without ownership or payment of rent

10.

How many people were members of your household at the time of the disaster? Include all people
who were living and sleeping in your home, including yourself.
Number of people
a. Children less than age 2



b. Children ages 2 to 17



c. Adults ages 18 to 29



d. Adults ages 30 to 64



e. Adults age 65 or older


4

11.

Did your household include any pets at the time of the disaster?
Yes
No

DISASTER IMPACT ON HOME
Next, we want to know what happened to your home as a result of the disaster.
12.

Did your home sustain physical damage as a result of the disaster?
Yes
No
 Go to Question 17
Don’t know
13.

Which parts of your home sustained damage? Select ALL that apply.
Exterior (roof, siding, windows)
Interior (ceilings, walls, floors, attic)
Frame (support beams)
Foundation or basement

14.

What caused the damage to your home? Select ALL that apply.
Rain
Flood
Mold/mildew
Mud/earth
Ice
Fire
Smoke
Tree
Wind
Other, please specify:

15.

In your opinion, how severe was the damage to your home?
None
Minor damage
Major damage, but able to be repaired
Destroyed

16.

Do you think your house is safe to live in?
Yes
No

17.

Next, we want to know whether your home lost any utilities as a result of the disaster.
As a result of the disaster, (If YES) About how long was your home
for any time, was your
without ______?
home without _______?
Choose one best answer.
Not
applicable

Yes

Less
than 4
hours

4-12
hours

13-24
hours

25-48
hours

More
than 48
hours





a. Electricity
b. Heat
c. Air conditioning
d. Piped water to sink,
toilet, showers, or
hose
e. Safe, drinkable tap
water
f. Natural gas
g. Landline telephone
service
h. Cellphone with
enough battery and
cellular service







HOUSEHOLD NEEDS
18.

Next, we want to know if your home had items that may be helpful during a disaster. For each
item, we want to know if anyone needed the item and if the item was in your home. We also
want to know if there was enough of the item or if you ran out of it.

During the disaster and its aftermath…
…did anyone
in your home
need this
item?
No
Yes
a. Non-perishable/canned
food
b. Stored water (bottles or
containers)

…was this
(If YES) … did
item available your home run
in your
out of this item?
home?
No
Yes
No
Yes

c. Batteries
d. Disposable
dishware/eating
utensils
e. Household cleaning
supplies
f. Matches/lighter
g. Plastic garbage bags
h. Plastic sheeting/tarps
i. Tape or duct tape
6








(If YES) …how many
days did this item
last before your
home ran out of it?
Number of days

19. During the disaster and its aftermath…
…did anyone in your home
need this item?
No
Yes

…was this item available in
your home?
No
Yes

a. Fire extinguisher
b. Flashlight, headlamp
c. GPS, maps, or compass
d. Manual can opener
e. Radio (battery-powered or hand-crank)
f. Whistle
g. Wrench/pliers

20.

During the disaster and its aftermath…
…did anyone
…was this
in your home
item available
need this
in your home?
item?
No
Yes
No
Yes
a. First aid supplies
b. Glasses or contact
lenses and solutions
c. Over-the-counter
medication
d. Personal hygiene
items
e. Prescription
medication
f. Wipes or moist
towelettes
g. Diapers
h. Infant
formula/powdered
milk
i. Special items for pets
j. Money/cash

(If YES) … did
your home
run out of this
item?
No
Yes



(If YES) …how many
days did this item last
before your home ran
out of it?
Number of days

21.

During the disaster and its aftermath…
…did anyone in your home
need this item?
No
Yes
a. Health-related documents
b. Important contact information
c. Insurance policies
d. Paper and writing utensils
e. Personal identification

…was this item available in
your home?
No
Yes

f. Blankets, sleeping bags
g. Complete change of clothes
h. Mosquito repellant
i. Sturdy shoes/boots
j. Weather-related clothing or gear (e.g.
cold-weather, rain wear)
22.

Did any household members leave your home within the first 72 hours (3 days) of the disaster to
get the following items? Select ALL that apply.
Not applicable, did not leave home within the first 72 hours
Water
Food
Infant formula/powdered milk
Medication (over-the-counter or prescription)
Other, please specify:

HEALTH NEEDS
23. Next, we want to know about symptoms of illness or injury among household members during
the first two weeks (14 days) after the disaster. Answer for all household members, including
yourself.
During the first two weeks (14 days) after
(IF YES) During the first two weeks (14 days) after
the disaster, did any household members,
the disaster, did any of those household members…
experience new symptoms of…
Obtain care at a
Call emergency Go to the
doctor’s office or
services (911) to hospital?
outpatient clinic?
get help?
No
Yes
No
Yes
No
Yes
No
Yes
a. Cough

b. Diarrhea
c. Fever
d. Nausea
e. Rash
f. Red eyes
g. Stomachache
h. Flu
i. Injury related to the disaster









8

Next, we want to know about health conditions
that household members had before the
disaster.

Before the disaster, did a doctor or other
health professional ever tell anyone in your
household that they or you had…

We also want to learn what happened to those
household members during the first 14 days
(two weeks) after the disaster.

28.

Answer for all household members, including
yourself.

Alzheimer’s or other dementia?
Yes
No  Go to Question 30
29.

Before the disaster, did a doctor or other
health professional ever tell anyone in your
household that they or you had…
24.

Allergies to mold or pollen?
Yes
No  Go to Question 26
25.

26.

During the first two weeks (14 days)
after the disaster, did any of those
household members experience the
following: Select ALL that apply.
Otherwise, leave blank.
Have symptoms that got worse
Obtain care at a doctor’s office or
outpatient clinic
Call emergency services (911) to get
help
Go to the hospital

30.

Angina or heart disease?
Yes
No  Go to Question 32
31.

Allergies to food, latex, household pets,
or other sources?
Yes
No  Go to Question 28
27.

32.

Anxiety?
Yes
No  Go to Question 34
33.

Before the disaster, did a doctor or other health professional ever tell anyone in your household that
they or you had…
34.

Asthma?

40.

Yes
No  Go to Question 36
35.

36.

38.

41.

Cancer?
Yes
No  Go to Question 38
37.

44.

Disability that affects physical functioning
or daily activities?
Yes
No  Go to Question 46
45.

Diabetes (excluding gestational)?
Yes
No  Go to Question 44
43.

Cerebrovascular disease or stroke?
Yes
No  Go to Question 40
39.

Depression?
Yes
No  Go to Question 42

Before the disaster, did a doctor or other
health professional ever tell anyone in your
household that they or you had…

46.

52.

Hypertension or high blood pressure?
Yes
No  Go to Question 48
47.

48.

53.

Kidney disease?
Yes
No  Go to Question 50
49.

50.

54.

During the first two weeks (14 days)
after the disaster, did any of those
household members, including
yourself, experience the following:
Select ALL that apply. Otherwise, leave
blank.
Have symptoms that got worse
Obtain care at a doctor’s office or
outpatient clinic
Call emergency services (911) to
get help
Go to the hospital

Another condition?
Yes, please specify:
No  Go to Question 56
55.

Lung disease (COPD, emphysema, or
chronic bronchitis)?
Yes
No  Go to Question 52
51.

Substance abuse disorder (alcohol or
drug)?
Yes
No  Go to Question 54

56.

Since the disaster, which of the following
problems has any household member
experienced? Select ALL that apply.
Otherwise, leave blank.
Difficulty concentrating
Felt agitated
Increased alcohol consumption
Increased drug use
Loss of appetite
Trouble sleeping or had nightmares
Witnessed firsthand violent behavior or
threats

57.

The next questions ask about how you have felt recently. Answer only for yourself about how
you have felt lately. Over the last 2 weeks, how often have you …
Not at all
Several
More than
Nearly
days
half the days
every day
a. Had little interest or pleasure in
doing things?
b. Felt down, depressed, or
hopeless?
c. Felt nervous, anxious, or on edge?
d. Been unable to stop or control
worrying?

PREPAREDNESS
The next set of questions ask about whether your household has prepared for a disaster.
58.

Before the disaster, did any household member put together a plan for what to do in a disaster?
Yes
No
 Go to Question 60
Don’t know
59.

What did the plan include? Select ALL that apply.
Emergency communication plan with list of numbers and contacts
Designated meeting place immediately outside home or close by
Designated meeting place outside neighborhood if you cannot return home
Designated place to keep important documents in a safe location
Multiple routes away from home in case evacuation is necessary
Other, please specify:

60.

Before the disaster, did any household member put together a plan for pets in a disaster? Select
ALL that apply.
Not appliable, no pets in home
Yes, we would take the pets with us
Yes, we would find a safe place for the pets
Yes, we would leave the pets behind with food and water
Other, please specify:

61.

An emergency supply kit is a collection of basic items that a household may need in a disaster.
The kit usually contains items such as food, water, and medical supplies. It is recommended
these items be stored together in containers that can be easily accessed, such as large boxes,
bins, or bags. An emergency supply kit is also known as disaster kit, emergency kit, survival
pack, grab bag, and go bag. Before now, had you ever heard of an emergency supply kit?
Yes
No

62.

At the time of the disaster, did your
household have an emergency supply
kit?
Yes
No  Go to Question 68
63.

What items were in your emergency
supply kit? Select ALL that apply.
Non-perishable/canned food
Stored water (bottles or containers)
Batteries
Disposable dishware/eating utensils
Household cleaning supplies
Matches/lighter
Plastic garbage bags
Plastic sheeting/tarps
Tape or duct tape
Fire extinguisher
Flashlight, headlamp
GPS, maps, or compass
Manual can opener
Radio (battery-powered or handcrank)
Whistle
Wrench/pliers
First aid supplies
Glasses or contact lenses and
solutions
Over-the-counter medication
Personal hygiene items
Prescription medication
Wipes or moist towelettes
Diapers
Infant formula/powdered milk
Special items for pets
Money/cash
Health-related documents
Important contact information
Insurance policies
Paper and writing utensils
Personal identification
Blankets; sleeping bag
Complete change of clothes
Mosquito repellant
Sturdy shoes/boots
Weather-related clothing or gear
(e.g. cold weather, rain wear)

64.

Why did your household prepare an
emergency supply kit? Select ALL
that apply.
Experienced disaster before
Threat of infectious diseases (e.g.,
H1N1, MERS, SARS, COVID-19)
Other, please specify:

65.

Overall, how helpful was the
emergency supply kit for your
household during the disaster?
Extremely helpful
Moderately helpful
Somewhat helpful
Slightly helpful
Not at all helpful

66.

What were the three most helpful
items in your emergency supply kit
during the disaster?
Item #1:
Item #2:
Item #3:
No items in the kit were used during
the disaster

67. What were the three missing items
from your emergency supply kit that
you wish you had during the
disaster?
Item #1:
Item #2:
Item #3:
No items in the kit were missing
during the disaster

68.

There are many reasons why a household may or may not prepare for a disaster. Please indicate
your level of agreement with the following statements. Please answer to the best of your ability
even if you did not have an emergency kit.
Strongly
Agree
Neither
Disagree Strongly
agree
agree nor
disagree
disagree
a. By keeping an emergency supply kit, my
household is improving its chance of
surviving a disaster.
b. My household will experience a
significant disaster soon.
c. I sometimes feel guilty that I have not
done enough to prepare for disasters.
d. It costs a lot of money to put together an
emergency supply kit.
e. I feel confident that I know how to
prepare for disasters.
f. Natural disasters in my area can do
serious harm to me or my property.
g. Someone in my household has a
disability or a health condition that might
affect their ability to prepare for a
disaster.
h. The risk of my household being affected
by infectious disease (H1N1, MERS,
SARS, COVID-19) is greater than the
risk of being affected by a disaster.

69.

Did anyone from your household obtain information about emergency supply kits from any of
the following sources before the disaster? Select ALL that apply. Otherwise, leave blank.
CDC’s website or social media
FEMA’s website or social media
American Red Cross’ website or social media
Ready.gov website or social media
A local government website or social media (state, county, or city)
A mobile app created by CDC, FEMA, or American Red Cross
Television, radio, or newspaper article
A presentation or print materials by local government (police, fire, emergency management, health)
Friends, family, word of mouth
Other, please specify:

PRIOR EXPOSURE TO
NATURAL DISASTERS

QUESTIONS ABOUT YOU
73.

70.

Before the disaster, did you or anyone in
your household experience any of the
following types of disasters? Select ALL
that apply. Otherwise, leave blank.

years old

Drought
Heatwave
Flood
Hurricane Category 1, 2, or tropical storm
Hurricane Category 3 or above
Severe weather with power outages
Winter storm
Tornado
Earthquake
Mudslide
Wildfire

71.

Before the disaster, had you or anyone in
your household ever worked or
volunteered in disaster response or
recovery?

74.

What is your sex?
Male
Female

75.

Are you the parent or guardian of a child
under the age of 18 living in your
household?
Yes
No

76.

Do you or any members of your
household identify as Hispanic, Latino, or
of Spanish origin?
Yes
No

77.

We’d like to know the race of members of
your household to make sure we are
collecting information from all types of
households. Which categories describe
the race of your household members?
Select ALL that apply.

Yes
No
Don’t know

72.

What is your age?

Community Emergency Response Team
(CERT) training is a program that
educates volunteers about disaster
preparedness and trains them in basic
disaster response skills. Have you or
anyone in your household taken a CERT
training?
Yes
No
Don’t know

White or Caucasian
Black or African American
American Indian or Alaskan Native
Asian
Native Hawaiian or Pacific Islander
Other (please specify):

78.

What is the highest level of school completed by any member of your household? Select one
answer.
Less than high school
Some high school
High school graduate with diploma or GED
Some college
Associate degree
Bachelor’s degree
Master’s or doctoral degree

79.

What is your household’s total annual income before taxes?
Less than $25,000
$25,000 to $49,999
$50,000 to $99,999
$100,000 to $149,999
$150,000 or more

80.

To mail you $10 for completing this survey, we need to collect your name and mailing address:
First Name:
Last Name:
Address Line 1:
Address Line 2:
City:
State:
Zip Code:

Thank you for your participation!
Please return the completed survey in the provided envelope.
If the envelope was not included or was lost, please return this questionnaire to:
RTI International
Attn: Data Capture (0213618.030)
5265 Capital Boulevard
Raleigh, NC 27690-1653
You will receive your $10 in three to four weeks.

File Type	application/pdf
File Title	Microsoft Word - Questionnaire_noruler_notrack_20200915
Author	hsanders
File Modified	2020-09-24
File Created	2020-09-15