Form 008-FY-21-103 (Tel 008-FY-21-103 (Tel National Household Survey on Disaster Preparedness (Tele

D EPARTMENT OF HOMELAND SECURITY

Federal Emergency Management Agency

National Household Survey on Disaster Preparedness

(Telephone) OMB No. 1660-0105

Expiration:

PAPERWORK BURDEN DISCLOSURE NOTICE

Public reporting burden for this data collection is estimated to average 11 minutes per response. The burden estimate includes the time for reviewing instructions, searching existing data sources, gathering and maintaining the data needed, and completing and submitting this form. You are not required to respond to this collection of information unless a valid OMB control number is displayed on this form. Send comments regarding the accuracy of the burden estimate and any suggestions for reducing the burden to: Information Collections Management, Department of Homeland Security, Federal Emergency Management Agency, 500 C Street. SW, Washington, DC  20472-3100, Paperwork Reduction Project (1660-0105) NOTE: Do not send your completed form to this address.

PRIVACY ACT STATEMENT

AUTHORITY: The Robert T. Stafford Disaster Relief and Emergency Assistance Act as amended, 42 U.S.C. § 5174 and Title 44 C.F.R. Part 206.117.

PRINCIPAL PURPOSE(S): This information is being collected for the primary purpose of obtaining necessary landowner consent to inspect site, place maintain, deactivate and/or remove temporary housing units provided by FEMA to eligible registered disaster survivors as part of its direct housing program under a Presidentially-declared disaster.

ROUTINE USE(S): The information on this form may be disclosed as generally permitted under 5 U.S.C. § 552a(b) of the Privacy Act of 1974, as amended. This includes using this information as necessary and authorized by the routine uses published in DHS/FEMA - 008 Disaster Recovery Assistance Files System of Records, 78 Fed. Reg. 25282 (Apr. 30, 2013), and upon written request, by agreement, or as required by law.

DISCLOSURE: The disclosure of information on this form is voluntary; however, failure to provide the information requested may delay or prevent the individual from receiving disaster-related temporary housing assistance.

Title: National Household Survey on Disaster Preparedness

(Telephone-Based Script)

SECTION I. INTRODUCTION

Hello, my name is [INSERT NAME] and I am calling from [INSERT CONTRACTOR] on behalf of Federal Emergency Management Agency or FEMA. Your phone number was randomly selected to take a special survey about disaster preparedness and we would like to include your opinions. After an initial screening, this survey should take about 15 minutes to complete and is completely voluntary.

These questions comply with the Privacy Act of 1974 and have been approved by the Office of Management and Budget under number 1660-0105. If you have any questions about the survey, you can reach a FEMA contact by emailing [email protected].

SECTION II. ELIGIBILITY

In order to keep our poll random, please think about everyone living in your household age 18 or older. May I speak with the adult who will celebrate the next birthday?(landline only)

	●	Yes #Continue interview with the adult who will celebrate the next birthday#
	●	No #Continue interview with the person who answered the phone#

Have I reached you on a landline phone or a cell phone?

	●	Landline phone #Continue#
	●	Cellphone #Skip to End/Terminate#
	●	Business line-landline or cell (volunteered) #Skip to End/Terminate#
	●	Don’t Know #Skip to End/Terminate#
	●	Prefer not to answer #Continue#

What is your age?

	●	Under 18 #Skip to End/Terminate#
	●	18-29
	●	30-39
	●	40-49
	●	50-59
	●	60-69
	●	70-79
	●	Over 80
	●	Prefer not to answer #Skip to End/Terminate#

What is the name of the state or territory you live in?

	●	(____) #Select from drop down #
	●	Don’t know #Skip to End/Terminate#
	●	Prefer not to answer #Skip to End/Terminate#
	●	I do not live in one of the above states or U.S. territories #Skip to End/Terminate#

What is your ZIP Code?

	●	(____) #Text entry#
	●	Don’t know #Skip to End/Terminate#
	●	Prefer not to answer #Skip to End/Terminate#

SECTION III. NATIONAL SAMPLE

The program office will select questions from the approved Question Bank. Question categories include: Stages of Change, Influencers, Preparedness Engagement, Assistance and Services, and Demographics. Question selection for this section will target the 7-8 minute range.

SECTION IV. HAZARD SAMPLES

In additional to the National sample questions, the program office will select hazard-specific questions from the approved Question Bank. These questions address preparedness for specific hazards and the respondents’ understanding of related protective actions. Question selection for this section will target an additional 7 minutes.

SECTION V. CONCLUSION

This completes the interview. Thank you for taking the time to answer these questions. Again, this is [INSERT NAME], with [INSERT CONTRACTOR]. On behalf of FEMA, I would like to thank you for your time. Your input is vital to helping FEMA help the nation get prepared for and know what to do during emergencies and disasters.

FEMA Form FF-008-FY-21-103 (formerly 008-0-15)

(03/21)