OMB CONTROL NUMBER: 0710-0017
OMB EXPIRATION DATE: XX/XX/XXXX
AGENCY DISCLOSURE NOTICE
The public reporting burden for this collection of information, 0710-0017, is estimated to average 20 minutes per survey, including the time for reviewing instructions, searching existing data sources, gathering and maintaining the data needed, and completing and reviewing the collection of information. Send comments regarding the burden estimate or burden reduction suggestions to the Department of Defense, Washington Headquarters Services, at [email protected]. Respondents should be aware that notwithstanding any other provision of law, no person shall be subject to any penalty for failing to comply with a collection of information if it does not display a currently valid OMB control number.
RESIDENTIAL
Background and Flood History
1. How many years have you been living at this address?
___________ years
2. Were you living at this residence during the (year) flood?
___NO ___YES
3. Was your residence flooded during the (year) flood?
___NO ___YES
4. Before the most recent flood, what would you have said the chance was of major flooding that would cause an evacuation of your neighborhood? (check one)
___NO CHANCE
___SLIGHT CHANCE
___MODERATE CHANCE
___STRONG CHANCE
___EXTREMELY LIKELY CHANCE
5. Before the flood this year, had your home ever been flooded? (check one)
___NO (SKIP to Q7) ___YES
6. Please give me the year that any previous floods occurred, and check whether or not you evacuated your home each time.
YEAR
______ ___ DID NOT EVACUATE ___EVACUATED
______ ___ DID NOT EVACUATE ___EVACUATED
______ ___ DID NOT EVACUATE ___EVACUATED
______ ___ DID NOT EVACUATE ___EVACUATED
______ ___ DID NOT EVACUATE ___EVACUATED
Structural Data
7. What is the five-digit zip code of this home?
8. What category best describes the style of this building?
(CIRCLE ONE ANSWER)
1. One-Story 5. 1-1/2 Story Finished 9. 3-1/2 Story Finished
2. Two-Story 6. 1-1/2 Story Unfinished 10. 3-1/2 Story Unfinished
3. Three-Story 7. 2-1/2 Story Finished 11. Bi-Level
4. Split Level 8. 2-1/2 Story Unfinished
9. Not counting your basement, attic, or garage, how many square feet of living area are in your home? (If respondent is unsure, ask for the dimensions and calculate.)
___________ SQUARE FEET
10. Does your home have a basement? (CIRCLE)
1. NO (Skip to 11)
2. YES
10a. If yes, please indicate the total basement area, in square feet, and the amount that is finished and unfinished? (If respondent is unsure, ask for the dimensions and calculate.)
TOTAL BASEMENT AREA: ________________ SQUARE FEET
FINISHED BASEMENT AREA: _____________ SQUARE FEET
UNFINISHED BASEMENT AREA: __________ SQUARE FEET
11. Do you have a garage on this property? (CIRCLE)
1. NO (Skip to 12)
2. YES
11a. Is the garage attached to the structure? (CIRCLE)
1. NO
2. YES
11b. How large is the garage in square feet? (If respondent is unsure, ask for the dimensions and calculate.)
_________ SQUARE FEET
12. Do you have a carport? (CIRCLE)
1. NO
2. YES
12a. How large is the carport in square feet? (If respondent is unsure, ask for the dimensions and calculate.)
_________ SQUARE FEET
13. What category best describes the heating and cooling system in this building?
(CIRCLE ONE ANSWER FOR MOST PROMINENT SYSTEM)
Heating Only:
1. Forced Air 6. Ceiling, Radiant Electric
2. Gravity Furnace 7. Baseboard, Electric
3. Floor Furnace 8. Baseboard, Hot Water
4. Wall Furnace 9. Radiators, Hot Water
(No Heat Ducts) 10. Radiators, Steam
5. Floor, Radiant Hot Water
Heating and Cooling:
11. Warmed and Cooled Air
12. Heat Pump System
Cooling Only:
13. Evaporative Water Cooler (Single or Short Ducts)
14. Refrigerated, with Condenser and Ducts
14. What is the primary exterior wall covering on this building?
(CIRCLE ONE ANSWER)
1. Plywood 4. Siding 7. Common Brick
2. Hardboard 5. Shingle 8. Face Brick
Sheets 6. Masonry 9. Stone
3. Stucco Veneer 10. Concrete Block
15. What is the primary roof covering of this building? (CIRCLE ONE ANSWER)
1. Composition Shingle 5. Concrete Tile 10. Plastic Tile
2. Built-up Rock 6. Clay Tile
3. Wood Shingle 7. Galvanized Metal
(Embedded in Asphalt) 8. Slate
4. Wood Shake 9. Composition Roll
16. How many fireplaces are in this home? _________ FIREPLACES
_______ FIREPLACES
17. How many square feet of each of the following types of porches are there in this home? (If you are unsure of square feet, please give dimensions.)
Slab ___________ SQUARE FEET
Or ( ____ Feet X ___ Feet)
Slab with Roof ___________ SQUARE FEET
Or ( ____ Feet X ___ Feet)
Wood Deck ___________ SQUARE FEET
Or ( ____ Feet X ___ Feet)
Enclosed Slab Porch ___________ SQUARE FEET
Or ( ____ Feet X ___ Feet)
Enclosed Wood Porch ___________ SQUARE FEET
Or ( ____ Feet X ___ Feet)
18. Do you have an elevator in your home?
___ Yes ___ No
19. How high is the first floor of your building above the lowest adjacent grade?
________FEET
20. How high is the first floor of your building above the where flood water would first enter your building (from considering windows and pipes into the foundation?
________FEET
Cost and Damages
The next group of questions is to determine flood damages to different types of property from the ___(year_______ flood.
21. Please indicate how high in feet and inches that the water was relative to the first
floor of the inside of your home.
______FEET; ______INCHES (ABOVE, BELOW) FIRST FLOOR LEVEL
[CIRCLE]
22. How long did the water remain in this building?
_____________ DAYS ____________ HOURS
23. Did the flooding make it necessary for you or other members of your household to stay in temporary residence due to evacuation or while your home was being repaired?
(CIRCLE)
1. NO (Skip to 24)
2. YES
23a. How many days did you spend in temporary residence due to the evacuation or while flood damage to your home was being repaired?
_____ DAYS
23b. How much money did your household spend on travel, (beyond your normal travel expense), and lodging (including trailer rental) due to your evacuation(s) for the ___________ flood?
______ DOLLARS
23c. Due to your evacuation, how much money did your household spend on food in excess of what you normally would have spent?
______ DOLLARS
24. For each motor vehicle, including cars, trucks, recreational vehicles, boats, and motorcycles, located at this residence during the flood, please indicate the dollar value, whether or not it was moved, the amount of damage to the vehicle, if any, and the level, in feet and inches, that the flood water reached above the bottom of the vehicle’s wheels.
Vehicle Category and Year (Categories include: sedan, van, sports utility, sports cars, pickup trucks, and motorcycles) |
Dollar Value |
Was it Moved? (Yes or no) |
Dollar Damage |
Depth of Water from the Bottom of the Vehicle |
Vehicle 1: |
$ ________
|
YES NO
|
$ ________
|
_______ FEET
|
Vehicle 2: |
$ ________
|
YES NO |
$ ________
|
_______ FEET
|
Vehicle 3: |
$ ________
|
YES NO |
$ ________
|
_______ FEET
|
Vehicle 4: |
$ ________
|
YES NO |
$ ________
|
_______ FEET
|
The following questions are to determine the dollar cost and unpaid hours for repair and cleanup of your home, and repair, replacement, and cleanup to the contents of your home that resulted from the __(YEAR)__ flood.
25. What was the cost of the structural damage to your home resulting from the (Year) flood? (Structural damage is defined as damage to any building components; including foundation, walls, floors, windows, roof, electrical systems, heating and cooling systems, plumbing, attached carpeting, attached shelves and cabinets, and built-in equipment and appliances.)
$_______________
25a. Which of the following is the primary source of your structure damage repair cost?
(circle one)
Contractor estimate (before repairs)
Contractor invoice (after repairs)
Your own assessment
Other _______________________
25b. What was the dollar cost to you for labor and supplies to clean up your home after the flood?
$________
25c. What was the total number of unpaid hours that you and others spent on repair and cleanup to your home after the flood?
______ UNPAID HOURS
Area of Damage |
Value of Damages |
||
|
In % of total Or in dollars |
Unpaid Hours to repair or install, in addition to $ spent |
|
1. Built-in shelves and appliances |
% |
$ |
|
2. Electrical |
% |
$ |
________ UNPAID HOURS |
3. Plumbing |
% |
$ |
________ UNPAID HOURS |
4. Exterior walls, windows, doors (painting included), and roofing |
% |
$ |
________ UNPAID HOURS |
5. Footings and foundation |
% |
$ |
________ UNPAID HOURS |
6. Interior doors and walls (painting included) |
% |
$ |
________ UNPAID HOURS |
7. Interior floors, carpet and ceilings |
% |
$ |
________ UNPAID HOURS |
8. Mechanical systems - heat, A/C, sump pump, built-in vacuum |
% |
$ |
________ UNPAID HOURS |
9. Outbuildings, decks, fireplaces and garages |
% |
$ |
________ UNPAID HOURS |
10. Outside property and landscaping |
% |
$ |
________ UNPAID HOURS |
11. Septic, sewer, and water systems |
% |
$ |
________ UNPAID HOURS |
Total |
100 % |
$ |
________ UNPAID HOURS |
26. a. |
Please list your total real estate damages into the following categories. |
b. |
Please also itemize any additional time that was spent on repairs other than paid labor hours. |
CONTENT DAMAGE
Content damage refers to damage to personal property kept inside the home or the garage that is not permanently affixed to the home.
27. What was the dollar cost of flood damage to the contents of your home, garage, and shed, excluding motor vehicles? (Only include content replacement and repairs, do not include repairs to the structure of the house).
$___________________
28. What was the total number of unpaid hours that you and others spent on repair of appliances, furniture, and other contents of your home?
______ UNPAID HOURS FOR CONTENT REPAIR
29. How much, if anything, did each of the following cost you in actual dollar expenditures as a result of the __(YEAR)__ flood?
a) Costs for moving furniture and other belongings? $__________
b) Costs for storing furniture and other belongings? $__________
c) Vandalism, looting, or theft costs? $__________
d) Costs from flooding-related medical problems? $__________
e) Any other costs due to the _______ flood. $__________
Describe: __________________________________________
__________________________________________________
Flood Warning and Response
30. Just before this year’s flood, did anyone at this residence hear from anyone or receive any other communication that flooding was possible? (CHECK ONE)
___NO (SKIP to Q48) ___YES
31. Did the FIRST such message that you received include any of the following information?
a) "Conditions are possible for a flood in your community." 1. NO 2. YES
b) "Watch the river or stream for flooding." 1. NO 2. YES
c) "It's possible your home will be flooded." 1. NO 2. YES
d) "Flooding will occur; take action." 1. NO 2. YES
e) "Evacuate your home." (no instructions) 1. NO 2. YES
f) "Evacuate your home." (with instructions) 1. NO 2. YES
g) The time that flooding would occur. 1. NO 2. YES
h) Other information in the message. 1. NO 2. YES
(Specify:)________________________________________________
32. What would you call this first message that you received? (circle one)
1. A FLOOD WATCH
2. A FLOOD WARNING
3. NEITHER ONE
4. UNSURE
33. On what date and at what time of day did you hear this message?
MO. DAY TIME (Hours and Minutes):
__/ __/ __:___ (circle one): AM or PM
34. How did you receive this first message? (CIRCLE ONLY ONE)
TEXT MESSAGE
SOCIAL NETWORKING WEBSITE (FACEBOOK, TWITTER, SNAPCHAT, etc.)
TV
RADIO
TELEPHONE BY A PUBLIC OR EMERGENCY WORKER
TELEPHONE BY OTHER
FACE TO FACE BY PUBLIC OR EMERGENCY WORKER
FACE TO FACE BY OTHER
LOUDSPEAKER
SIREN
C.B., HAM RADIO or POLICE SCANNER
NEWSPAPER
OBSERVING THE CREEK OR RIVER WATER LEVELS
OTHER ______________________________________
35. On what date, and at what approximate time, did the flood waters reach your property? [Put a Number on each Blank or Check [ ] if DON'T KNOW]
DATE TIME (Hours and Minutes):
__________ __: ___ (circle one): AM or PM
36. Of each of the following actions, please answer yes or no to each to indicate the actions that you took, if any, as a result of this first message you heard. Remember that these are only actions with respect to the first message you heard.
[CIRCLE YES OR NO FOR EACH.]
In response to the first message did you :
a) Listen to TV or Radio? 0. NO 1. YES
b) Contact family members? 0. NO 1. YES
c) Contact other people? 0. NO 1. YES
d) Disconnect appliances? 0. NO 1. YES
e) Pack or prepare any household possessions
for an evacuation? 0. NO 1. YES
f) Elevate possessions above the floor of the first
story of your house? 0. NO 1. YES
g) Move any possessions to a safer location
outside of the house? 0. NO 1. YES
h) Go out and look at the stream? 0. NO 1. YES
I) Move cars or other vehicles to higher ground? 0. NO 1. YES
j) Evacuate from the structure? 0. NO 1. YES
k) Take any other actions? (if yes, list below) 0. NO 1. YES
_______________________________________________
37. On a scale of 1 to 10 how would you estimate the strength of your belief in this first message? (1 represents total disbelief and 10 represents total belief)
__________ (fill-in with number between 1-10)
38. The previous questions asked about the first message you received. Did you receive a DIFFERENT MESSAGE LATER ON indicating that flooding was possible or the possibility of flooding had increased?
0. NO If No, SKIP to Q 48
1. YES
39. Did the SECOND message that you received include any of the following information?
a) "Conditions possible for a flood
in your community." 0. NO 1. YES
b) "Watch the river or stream for flooding." 0. NO 1. YES
c) "It is possible your home will be flooded." 0. NO 1. YES
d) "Flooding will occur; take action." 0. NO 1. YES
e) "Evacuate your home." (no instructions) 0. NO 1. YES
f) "Evacuate your home." (with instructions) 0. NO 1. YES
g) The time that flooding would occur. 0. NO 1. YES
h) Other information in the message. 0. NO 1. YES
(Specify:)_______________________________________
40. What would you call this SECOND message that you received? (circle one)
1. A FLOOD WATCH
2. A FLOOD WARNING
3. NEITHER ONE
4. UNSURE
41. On what date, and what time of day did you hear this message?
MO. DAY TIME (Hours and Minutes):
__/ __/ __:___ (circle one): AM or PM
42. How did you hear this SECOND message? (circle one only)
TEXT MESSAGE
SOCIAL NETWORKING WEBSITE (FACEBOOK, TWITTER, SNAPCHAT, etc.)
TV
RADIO
TELEPHONE BY A PUBLIC OR EMERGENCY WORKER
TELEPHONE BY OTHER
FACE TO FACE BY PUBLIC OR EMERGENCY WORKER
FACE TO FACE BY OTHER
LOUDSPEAKER
SIREN
C.B., HAM RADIO or POLICE SCANNER
NEWSPAPER
OBSERVING THE CREEK OR RIVER WATER LEVELS
OTHER ______________________________________
43. Please answer yes or no to each to indicate which of the following actions, if any, that you took as a result of this SECOND message that you heard.
[CIRCLE YES OR NO FOR EACH.]
In response to the second message did you :
a) Listen to TV or Radio? 0. NO 1. YES
b) Contact family members? 0. NO 1. YES
c) Contact other people? 0. NO 1. YES
d) Disconnect appliances? 0. NO 1. YES
e) Pack or prepare any household possessions for
evacuation? 0. NO 1. YES
f) Elevate possessions above the floor of the first story
of your house? 0. NO 1. YES
g) Move any possessions to a safer location outside
of the house? 0. NO 1. YES
h) Go out and look at the stream? 0. NO 1. YES
I) Move cars or other vehicles to higher ground? 0. NO 1. YES
j) Did the SECOND message cause you to evacuate
from the structure? 0. NO 1. YES
k) Did the SECOND message cause you to take
any other actions? (If yes, list below) 0. NO 1. YES
____________________________________________________________________
44. On a scale of 1 to 10 how would you estimate the strength of your belief in this second message? (1 = total disbelief, and 10 = total belief)
__________ (fill-in with number between 1-10)
45. After receiving the second message, did you receive any later messages that caused you to take further action?
0. NO If No, SKIP to Q 48.
1. YES
2. UNSURE
46. Please describe the (those) later message(s).
____________________________________________________
____________________________________________________
47. What additional actions, if any, did you take as a result of hearing the (those) later message(s)?
____________________________________________________
____________________________________________________
->48. Do you have any suggestions on ways to improve the current flood warning system?
_____________________________________________________________________
_____________________________________________________________________
49. For each of the following categories, please tell me the total number of people who were in the residence, the number who did evacuate, and the number who did not: (Put a Number or Zero on each Blank)
EVAC- DID
TOTAL UATED NOT
a) Household members under 13: _____ _____ _____
b) Household members 13-64 yrs. old: _____ _____ _____
c) Household members 65 and over: _____ _____ _____
--------------------------------------------------------------------
d) Non-household members < 13: _____ _____ _____
e) Non-household members 13-64 yrs. old: _____ _____ _____
f) Non-household members 65 and over: _____ _____ _____
[SKIP to Q 54 , if no one evacuated.]
50. During the flooding this year, how many people evacuated from your household using each of the following modes of transportation?
[Put a Number or Zero on each blank.]
Number Evacuating
a) CAR OR TRUCK? ________
b) BOAT? ________
c) WALKING? ________
d) OTHER TRANSPORTATION? ________
(What kind?)___________________________________
51. For you and others who decided to evacuate from your residence, which of the following affected the decision to evacuate? Please answer yes or no to each.
[CIRCLE YES OR NO FOR EACH.]
Did you evacuate because of:
a) Messages on TV or Radio? 0. NO 1. YES
b) A telephone message from friends or relatives? 0. NO 1. YES
c) A face to face message from friends or relatives? 0. NO 1. YES
d) Telephone messages from local officials? 0. NO 1. YES
e) Face to face messages from local officials? 0. NO 1. YES
f) Experience you or other residents had with floods
in previous years? 0. NO 1. YES
g) High stream level or flood waters close to
your residence? 0. NO 1. YES
h) Because it was physically impossible to remain
in the structure? 0. NO 1. YES
I) To find or meet family members? 0. NO 1. YES
j) Because the neighbors were evacuating? 0. NO 1. YES
k) Other Reason(s) for Decision to Evacuate? 0. NO 1. YES
[Probe for Reasons]______________________________________
52. On what date, and at what time of day, did you last leave your house to go to a place of safety?
Date _____________________________
MO. DAY TIME (Hours and Minutes):
__/ __/ __:___ (circle one): AM or PM
53. How much time did it take in your evacuation to get out of the area of flood danger?
[Put a Number or a Zero on each Blank]
_____HOURS; ______MINUTES
Check Box if everyone evacuated [ ], and SKIP to Q31.
->54. If you and others did NOT evacuate when warned, which of the following affected your decision NOT to evacuate or to delay doing so?
[CIRCLE YES OR NO FOR EACH.]
a) Did not believe messages on TV or Radio? 0. NO 1. YES
b) Telephone message from friends or relatives? 0. NO 1. YES
c) Face to face message from friends or relatives? 0. NO 1. YES
d) Telephone messages from local officials? 0. NO 1. YES
e) Face to face messages from local officials? 0. NO 1. YES
f) Experience you or other residents had with floods in
previous years? 0. NO 1. YES
g) Location of flood waters in relation to the residence? 0. NO 1. YES
h) Because it was physically impossible to
leave the structure? 0. NO 1. YES
I) Because of the location of your family members? 0. NO 1. YES
j) Because the neighbors were not evacuating? 0. NO 1. YES
k) Fear of looting? 0. NO 1. YES
l) Other Reason(s) for Not Evacuating? 0. NO 1. YES
[specify]__________________________________________________________
The next question is to determine how you learned about the approaching flood and how you responded at the time.
55. What actions, if any, did you take to safeguard your property immediately prior to
flooding and what were the damages prevented by each action?
(PLEASE CIRCLE ALL THAT APPLY AND INDICATED THE DOLLARS DAMAGES PREVENTED FOR EACH ACTION.)
Damage Preventive Action (CIRCLE ALL THAT APPLY) |
$ Damage Prevented |
Hours Spent on Damage Prevention |
Cost of Materials for Prevention |
1. Moved contents to higher ground |
$___________ |
________ HOURS |
$___________ |
2. Elevated contents to a higher spot in the building |
$___________ |
________ HOURS |
$___________ |
3. Turn off electrical equipment |
$___________ |
________ HOURS |
$___________ |
4. Sandbagged the outside of the building |
$___________ |
________ HOURS |
$___________ |
5. Used another type of temporary barrier |
$___________ |
________ HOURS |
$___________ |
6. Moved vehicles to higher ground |
$___________ |
________ HOURS |
$___________ |
7. Other action _______________________
|
$___________ |
________ HOURS |
$___________ |
8. None |
|
|
|
RESIDENTIAL
| File Type | application/vnd.openxmlformats-officedocument.wordprocessingml.document |
| File Modified | 0000-00-00 |
| File Created | 0000-00-00 |