Form FF-119-FY-23-100 FEMA Congressional Mental Health Emergency Manager Welln

OMB. No. 1660-NW164

Expiration: XX-XX-XXXX

Mental Health Impact of Disaster Response and Recovery

(Insert Informed consent here prior to data collection- have participants choose to move forward or voluntarily quit)

1. Choose your current deployment/activation status: (multiple choice)

   1. Physically deployed

   2. Virtually deployed

2. If you are supporting a disaster, enter the associated Disaster Response #: (free text)

3. What is your age: Free text

4. What is your current emergency manager role?

(Free text)

5. Does your role require you to work directly with disaster survivors?

   1. Yes

   2. No

6. Approximately how many total deployments/activations have you experienced? (free text)-number only

7. How many days were you deployed/activated for this most recent disaster?

   1. Free text (number only)

8. Did you begin to feel a change in overall wellbeing during this deployment/activation ? If so, approximately how many days into the deployment?

   1. Free text (number only)

9. What aspects of deployment/activation do you perceive to be stressful? (select all that apply)

   1. Number of Communications (e-mails, alerts, phone calls, meetings)

   2. Accountability

   3. Job Duties

   4. Other (free text)

10. What aspects of deployment/activation do you enjoy (select all that apply)?

    1. Job Duties

    2. Teamwork

    3. fast-paced Environment

    4. Overtime/Pay

    5. Travel Opportunities

    6. Other (free text)

11. Based on your deployment/activation experience, what things do you do to lower your stress levels and did you feel they were helpful? Free text

(Intro phrase to participants to section II of survey) “Now we will assess your experience of stress during disaster response and recovery”.

12. In the last month, how often have you been upset because of something that happened unexpectedly?

A) Never

B) Almost never

C) C) Sometimes

D) Fairly often

E) Very often

13) In the last month, how often have you felt that you were unable to control the

important things in your life?

A) Never

B) Almost never

C) C) Sometimes

D) Fairly often

E) Very often

14) In the last month, how often have you felt nervous and stressed?

A) Never

B) Almost never

C) C) Sometimes

D) Fairly often

E) Very often

15) In the last month, how often have you felt confident about your ability to handle

your personal problems?

A) Never

B) Almost never

C) C) Sometimes

D) Fairly often

E) Very often

16) In the last month, how often have you felt that things were going your way?

A) Never

B) Almost never

C) C) Sometimes

D) Fairly often

E) Very often

17) In the last month, how often have you found that you could not cope with

all the things that you had to do?

A) Never

B) Almost never

C) C) Sometimes

D) Fairly often

E) Very often

18) In the last month, how often have you been able to control irritations in

your life?

A) Never

B) Almost never

C) C) Sometimes

D) Fairly often

E) Very often

19) In the last month, how often have you felt that you were on top of things?

A) Never

B) Almost never

C) C) Sometimes

D) Fairly often

E) Very often

20) In the last month, how often have you been angered because of things that

happened that were outside of your control?

A) Never

B) Almost never

C) C) Sometimes

D) Fairly often

E) Very often

21) In the last month, how often have you felt difficulties were piling up so high that you could not overcome them?

A) Never

B) Almost never

C) C) Sometimes

D) Fairly often

E) Very often

(Intro phrase to participants to section III of survey) “Now we will assess your experience of strong emotions during disaster response and recovery”.

22) In the last month, have you experienced repeated, disturbing memories, thoughts, or images of a stressful experience from the past?

a. Not at all

b. A little bit

c. Moderately

d. Quite a bit

e. Extremely

23) In the last month, have you experienced repeated, disturbing dreams of a stressful experience from the past?

a. Not at all

b. A little bit

c. Moderately

d. Quite a bit

e. Extremely

24) . In the last month, have you experienced suddenly acting or feeling as if a stressful experience were happening again (as if you were reliving it)?

a. Not at all

b. A little bit

c. Moderately

d. Quite a bit

e. Extremely

25). In the last month, have you experienced feeling very upset when something reminded you of a stressful experience from the past?

a. Not at all

b. A little bit

c. Moderately

d. Quite a bit

e. Extremely

26) In the last month, have you experienced having physical reactions (e.g., heart pounding, trouble breathing, or sweating) when something reminded you of a stressful experience from the past?

a. Not at all

b. A little bit

c. Moderately

d. Quite a bit

e. Extremely

27) In the last month, have you experienced avoid thinking about or talking about a stressful experience from the past or avoid having feelings related to it?

a. Not at all

b. A little bit

c. Moderately

d. Quite a bit

e. Extremely

28) In the last month, have you experienced avoid activities or situations because they remind you of a stressful experience from the past?

a. Not at all

b. A little bit

c. Moderately

d. Quite a bit

e. Extremely

29) In the last month, have you experienced trouble remembering important parts of a stressful experience from the past?

a. Not at all

b. A little bit

c. Moderately

d. Quite a bit

e. Extremely

30) In the last month, have you experienced loss of interest in things that you used to enjoy?

a. Not at all

b. A little bit

c. Moderately

d. Quite a bit

e. Extremely

31) In the last month, have you experienced feeling distant or cut off from other people?

a. Not at all

b. A little bit

c. Moderately

d. Quite a bit

e. Extremely

32) In the last month, have you experienced feeling emotionally numb or being unable to have loving feelings for those close to you?

a. Not at all

b. A little bit

c. Moderately

d. Quite a bit

e. Extremely

33) In the last month, have you experienced feeling as if your future will somehow be cut short?

a. Not at all

b. A little bit

c. Moderately

d. Quite a bit

e. Extremely

34) In the last month, have you experienced trouble falling or staying asleep?

a. Not at all

b. A little bit

c. Moderately

d. Quite a bit

e. Extremely

35) In the last month, have you experienced feeling irritable or having angry outbursts?

a. Not at all

b. A little bit

c. Moderately

d. Quite a bit

e. Extremely

36) In the last month, have you experienced having difficulty concentrating?

a. Not at all

b. A little bit

c. Moderately

d. Quite a bit

e. Extremely

37) In the last month, have you experienced being “super alert” or watchful on guard?

a. Not at all

b. A little bit

c. Moderately

d. Quite a bit

e. Extremely

38) In the last month, have you experienced feeling jumpy or easily startled?

a. Not at all

b. A little bit

c. Moderately

d. Quite a bit

e. Extremely

PAPERWORK BURDEN DISCLOSURE NOTICE

                                                               

Public reporting burden for this data collection is estimated to average .5 hour 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-NW164) NOTE: Do not send your completed form to this address.

FEMA Form FF-119-FY-23-100