AppxE General Survey SAMPLE
AppxE General Survey SAMPLE.docx
[ATSDR] Assessment of Chemical Exposures (ACE) Investigations
AppxE General Survey SAMPLE
OMB: 0923-0051
Appendix E: General Survey SAMPLE
Form Approved OMB
No. 0923-0051 Exp
Date XX/XX/XX
Survey
Formatting Key:
Notes
to survey developers:
Denoted
as (Note: as gray text within a set of parentheses and preceded by
the word ‘Note’)
These
notes are intended to be followed and deleted before distributing
to respondents.
Notes
for online survey tool development (i.e. REDCap, Epi Info,
etc.):
Denoted
by yellow boxes
These
boxes are expected to be removed from the survey before
distributing to respondents and/or publishing to online survey
tool
In
the REDCap version of the survey, these notes will be entered
into the ‘field note’ section of the
field/question.
Notes
to respondents:
Denoted
in bold, italics, and underlined writing, ex. (Note to
respondent:)
Notes to survey developers:
Denoted as (Note: as gray text within a set of parentheses and preceded by the word ‘Note’)
These notes are intended to be followed and deleted before distributing to respondents.
Notes for online survey tool development (i.e. REDCap, Epi Info, etc.):
Denoted by yellow boxes
These boxes are expected to be removed from the survey before distributing to respondents and/or publishing to online survey tool
In the REDCap version of the survey, these notes will be entered into the ‘field note’ section of the field/question.
Notes to respondents:
Denoted in bold, italics, and underlined writing, ex. (Note to respondent:)
Public reporting burden of this collection of information is
estimated to average 60 minutes per response, including the time
for reviewing instructions, searching existing data sources,
gathering and maintaining 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 Clearance Officer, 1600 Clifton
Road NE, MS H21–8, Atlanta, Georgia 30329 ATTN: PRA
(0923-0051)
For Official interviewer use only
Household ID _____________Participant ID ______________ Interviewer Initials _____ ____ ___
Interview location: ____________________________________________________________________
Date ___/___ ___ /___ ___ ___ ___ (mm/dd/yyyy) Time you started the survey ___:___ (am/pm)
________________________________________________________________________________________________
Adult Section
Demographic and Contact Information
1. Name _______________ , ________________ ___
Last First M.I.
2. Date of Birth
____ /___ ___ /___ ___ ___ ___ (mm/dd/yyyy)
3. Sex (select one)
Male
Female
Don’t know/refused
Other
4. What is your marital status?
Married - spouse present
Married - spouse absent
Separated
Divorced
Widowed
Never Married
5. What is your race and/or ethnicity? (Select all that apply)
American Indian or Alaska Native (For example, Navajo Nation, Blackfeet Tribe of the Blackfeet Indian Reservation of Montana, Native Village of Barrow Inupiat Traditional Government,
Nome Eskimo Community, Aztec, Maya, etc.)
Asian (For example, Chinese, Asian Indian, Filipino, Vietnamese, Korean, Japanese, etc.)
Black or African American (For example, African American, Jamaican, Haitian, Nigerian, Ethiopian, Somali, etc.)
Hispanic or Latino (For example, Mexican, Puerto Rican, Salvadoran, Cuban, Dominican, Guatemalan, etc.)
Middle Eastern or North African (For example, Lebanese, Iranian, Egyptian, Syrian, Iraqi, Israeli, etc.)
Native Hawaiian or Pacific Islander (For example, Native Hawaiian, Samoan, Chamorro, Tongan, Fijian, Marshallese, etc.)
White (For example, English, German, Irish, Italian, Polish, Scottish, etc.)
6. What is the highest level of education you completed?
Less Than High School
High School Graduate or Equivalent
Some College, Trade School
Junior or Community College
University/College Graduate (4-year degree)
Graduate School or Higher
7. Home Address
Street: ________________________________________________________
City:______________________ County:________________________
State:_______________ ZIP:__________________
8. What are the best telephone numbers to reach you?
A. (_ _ _ ) _ _ _ -_ _ _ _ Cell Home Work
B. (_ _ _ ) _ _ _ -_ _ _ _ Cell Home Work
9. Best email address_______________________________
10. What social media accounts do you use? This helps us know how to best communicate with you. (Select all that apply.) Facebook Twitter Instagram Other Refuse
Notes
for online survey tool development:
Apply
branching logic in the specified questions below:
ONLY
when ‘Same as home address above’ is selected for the
question: “While you were in the affected area during the
incident, did you smell an odor you thought was caused by the
incident?”, hide the following: “While you were in the
affected area during the incident, did you smell an odor you
thought was caused by the incident?”, hide the following:
Street:
City: County: State: Zip:
If
you are not sure of the exact address, please provide as much
location information as possible (i.e. closest landmark, building
name, cross streets).
Under
question: “Do you think you were in contact with
contaminants?”
Make
“If yes, why do you think/know you were contaminated?”
visible ONLY when ‘Yes’ is selected
Remove
‘If yes,’
ONLY
when ‘yes’ is selected for the question: “While
you were in the affected area during the incident, did you smell
an odor you thought was caused by the incident?”, make the
following questions visible:
For
how long did you smell this odor?
How
intense was the smell?
What
would you say the odor smelled like? (Check all that apply)
Did
you receive instructions to shelter in place?
ONLY when ‘yes’
is selected for the question: “Did you receive instructions
to shelter in place?”, make the following question visible:
How
long did you shelter in place?
Remove
(if yes, to 9)
Did
you receive instructions to evacuate?
ONLY
when ‘yes’ is selected for the question: “Did
you receive instructions to evacuate?”, make the following
question visible:
Did
you evacuate from the affected area?
Remove
(if yes, to 11)
How
did you first learn you needed to shelter in place/evacuate?
ONLY
when ‘yes’ is selected for the question: “Did
you evacuate from the affected area? “, make the
following question visible:
How
long did you evacuate for?
Remove
(if yes, to 11)
At
approximately what time did you evacuate?
If
you evacuated, did you take any pets with you?
Only
when ‘yes’ is selected for, Were
you a responder (career and/or volunteer) in any way to this
incident? Say” You will be prompted later to
provide more information about your experiences as a responder”
Apply branching logic in the specified questions below:
ONLY when ‘Same as home address above’ is selected for the question: “While you were in the affected area during the incident, did you smell an odor you thought was caused by the incident?”, hide the following: “While you were in the affected area during the incident, did you smell an odor you thought was caused by the incident?”, hide the following:
Street: City: County: State: Zip:
If you are not sure of the exact address, please provide as much location information as possible (i.e. closest landmark, building name, cross streets).
Under question: “Do you think you were in contact with contaminants?”
Make “If yes, why do you think/know you were contaminated?” visible ONLY when ‘Yes’ is selected
Remove ‘If yes,’
ONLY when ‘yes’ is selected for the question: “While you were in the affected area during the incident, did you smell an odor you thought was caused by the incident?”, make the following questions visible:
For how long did you smell this odor?
How intense was the smell?
What would you say the odor smelled like? (Check all that apply)
Did you receive instructions to shelter in place?
ONLY when ‘yes’ is selected for the question: “Did you receive instructions to shelter in place?”, make the following question visible:
How long did you shelter in place?
Remove (if yes, to 9)
Did you receive instructions to evacuate?
ONLY when ‘yes’ is selected for the question: “Did you receive instructions to evacuate?”, make the following question visible:
Did you evacuate from the affected area?
Remove (if yes, to 11)
How did you first learn you needed to shelter in place/evacuate?
ONLY when ‘yes’ is selected for the question: “Did you evacuate from the affected area? “, make the following question visible:
How long did you evacuate for?
Remove (if yes, to 11)
At approximately what time did you evacuate?
If you evacuated, did you take any pets with you?
Only when ‘yes’ is selected for, Were you a responder (career and/or volunteer) in any way to this incident? Say” You will be prompted later to provide more information about your experiences as a responder”
Location And Exposure Information Including Work
These next few questions will ask about where you were during the Incident and what exposures you may have had.
Within the affected area, where did you spend the most time during the Incident?
Same as home address above (Skip to next question)
Street: ________________________________________________________
City:______________________ County:________________________
State:_______________ ZIP:__________________
*If you are not sure of the exact address, please provide as much location information as possible (i.e. closest landmark, building name, cross streets). _____________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________
Referring to the question above, what was your physical location during the Incident? (Select all that apply.)
Inside building
Outside
Inside a car/vehicle
Other ________________
How long were you in the affected area during the Incident? (Note to Survey Developer: Response choices may vary with specific incident.)
Less than an hour
1-5 hours
6-12 hours
13 hours- 1 day
2-4 days
5 or more days
Do you think you were in contact with contaminants?
Yes
If yes, why do you think/know you were contaminated? ____________________________________
No
Unsure
While you were in the affected area during the incident, did you smell an odor you thought was caused by the Incident?
Yes
No
I don’t know
For how long did you smell this odor? (Note to Survey Developer: response choices may vary with specific incident.)
Less than an hour
1-5 hours
6-12 hours
13-1 day
2-4 days
5 or more days
How intense was the smell?
Light
Moderate
Severe
What would you say the odor smelled like? (Select all that apply.) (Note to Survey Developer: response choices may vary with specific incident.)
Gasoline
Rotten eggs
Chemical smell
Paint
Paint thinner
Car tires or asphalt
Bug spray
Sweet smell
Smoke
Sewage
Other, please specify:____________________________________________
Did you receive instructions to shelter in place?
Yes
No
I don’t know
(If yes, to 9) How long did you shelter in place? (Note to Survey Developer: response choices may vary with specific incident.)
I did not shelter in place
Less than an hour
1-5 hours
6-12 hours
13 hours-1 day
2-4 days
5 or more days
Did you receive instructions to evacuate?
Yes
No
I don’t know
N/A
Did you evacuate from the affected area?
Yes, I evacuated
No, I did not evacuate
I don’t know
N/A
At approximately what date and time did you evacuate?
____ /___ ___ /___ ___ ___ ___ (mm/dd/yyyy)
____:_____
AM
PM
Hour Min
How long did you evacuate for? (Note to Survey Developer: response choices may vary with specific incident.)
I did not evacuate
Less than an hour
1-5 hours
6-12 hours
13 hours-1 day
2-4 days
5 or more days
15. Do you currently work? This includes part-time and full-time jobs, contract and volunteer work?
Yes
No
16. What kind of work do you do? What is your job title? (e.g., registered nurse, janitor, cashier, auto mechanic, etc.) _________________________________________________________
17. What kind of business or industry do you work in? (e.g., hospital, elementary school, clothing manufacturing, restaurant, etc.)
________________________________________________________________________
18. How long have you worked in your primary job?
Less than 6 months
At least 6 months but less than a year
1-5 years
6-10 years
11-20 years
21-30 years
More than 30 years
19. On average, how many hours per week do you work at your primary job? ____________hours
20. Have you ever served on active duty in the U.S. Armed Forces, military Reserves or National Guard? (Does not include training in the Reserves or National Guard, but DOES include activation, in the last 12 months)
Yes, now on active duty
Yes, on active duty in the past, but not now
No, training or Reserves or National Guard only
No, never served in the military
Prefer not to answer
21. During the “exposure window” (define), did you report to a physical working location for your job within the “affected area” (define)? (see map)
Yes
No
Prefer not to answer
Unsure
Did you need to stay home from work or miss work due to symptoms you experienced after the Incident? Yes
How many days did you miss?_________days
No
Unsure
Did you need to modify your regular work duties due to symptoms you experienced after the Incident?
Yes
How many days of modified work duties did you need?_________days
No
Unsure
What, if anything, could have been done differently to improve the response to this incident?
Decontaminations
Notes for online survey tool development: Apply
branching logic in the specified questions below: ONLY when
‘yes’ is selected for the following question: ‘Were
you told by a responder/healthcare professional that you were in
contact with contaminants?’, make the following questions
visible: Were your
measurements of exposure taken by an emergency responder or
healthcare worker (examples)? ONLY when
‘yes’ is selected for the following question: ‘Were
your measurements of exposure taken by an emergency responder or
healthcare worker (examples)?’, make the following questions
visible: Please
explain the measurements taken ONLY when
‘yes’ is selected for the following question: ‘Were
you decontaminated (i.e. your clothing was removed and/or your
body was washed, etc.)?’, make the following questions
visible: How were
you decontaminated?
Where
were you decontaminated? This question is asking for a geographic
location, not a place on their body.
At
approximately what time were you decontaminated?
Were you told by a responder/healthcare professional that you were in contact with contaminants?
Were your measurements of exposure taken by an emergency responder or healthcare worker (measurement of exposure for specific investigation)?
Yes
No
Unsure
Please explain the measurements taken _________________________________________________
Were you told to decontaminate?
Yes
No
Unsure
If yes, where on your body? ____________________________________________________________
Were you decontaminated (i.e. your clothing was removed and/or your body was washed, etc.)?
Yes
No
Unsure
If yes, to 4. How were you decontaminated? (Select all that apply.)
Clothing removal
Water
Soap and water
Other (Please specify): ___________________________________________________________________
Where were you decontaminated? (This question is asking for a geographic location, not a place on the body.)
Community Resource Center (CRC)
Mobile decontamination unit
Emergency room (ER)
Other (Please specify):
At approximately what day and time were you decontaminated?
Date ___/___ ___ /___ ___ ___ ___ (mm/dd/yyyy) Time ___:___ (am/pm)____:_____
Did you go to a Community Resource Center (CRC)? (Note to Survey Developer: this question in generally only used for nuclear/radiologic events )
Yes
No
Unsure
If you went to a Community Resource Center (CRC) what tracking number did they give you?
_______________________________
Physical Health Symptoms after the Incident
Notes for online survey tool development:
Apply
branching logic in the specified questions below: ONLY when
‘New symptoms or conditions?’ or ‘Worsening of
your preexisting symptoms or conditions?’ are selected for
the following question: ‘Since the Incident have you had’,
make the following questions visible: No, I
do not have this new or worsening symptom or condition Yes, I
am experiencing this new symptom or condition Yes, I
am experiencing worsening of this preexisting symptoms or
condition Yes, I am
still experiencing these symptoms/conditions No, I am
not still experiencing these symptoms/conditions
Here you will be asked some questions about symptoms that could be related to the Incident.
(Note to Survey Developer: This list should be narrowed down ahead of time with a toxicologist, physician, or other expert.)
Since the incident have you had: check all that apply
New symptoms or conditions?
Worsening of your preexisting symptoms or conditions?
No new symptoms or conditions and no worsening of preexisting symptoms or conditions. skip to next section.
If you have had new symptoms or conditions or worsening of preexisting symptoms or conditions, please fill out the table provided below for each listed symptom.
|
Have you had any new symptoms or worsening of preexisting symptoms because of the Incident? |
At the time of completing this survey are you still experiencing these symptoms? |
|||
Symptom |
No, I do not have this new or worse symptom skip to next symptom |
Yes, I am experiencing this new symptom |
Yes, I previously had this symptom, and it became worse after the Incident. |
Yes, I am still experiencing this symptom |
No, I am not still experiencing this symptom |
GENERAL |
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EYES |
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EAR/NOSE/THROAT |
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NERVOUS SYSTEM |
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MUSCLE/JOINT/BONES |
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PULMONARY (LUNGS) |
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CARDIOVASCULAR (HEART) |
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STOMACH/INTESTINES |
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SKIN/Hair/Nails/Teeth |
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KIDNEY/BLADDER/GENITAL |
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Physical Health Questions:
Thinking about your physical health (your body's ability to function normally) for how many days in the days/week/month before the Incident was your physical health NOT good? (Note to Survey Developer: change timeframe based on exposure period and time since incident)
_________days
Thinking about your physical health (your body's ability to function normally) for how many days in the days/week/month during the Incident was your physical health NOT good? (Note to Survey Developer: change timeframe based on exposure period and time since incident)
_________days
Thinking about your physical health (your body's ability to function normally) for how many days in the days/week/month after the Incident was your physical health NOT good? (Note to Survey Developer: change timeframe based on exposure period and time since incident)
_________days
Thinking about your physical health, for how many days in the week/month before the Incident did poor physical health keep you from doing your normal activities, such as self-care, work, or recreation? (Note to Survey Developer: change timeframe based on exposure period and time since incident)
_________days
Thinking about your physical health, for how many days in the week/month during the Incident did poor physical health keep you from doing your normal activities, such as self-care, work, or recreation? (Note to Survey Developer: change timeframe based on exposure period and time since incident)
_________days
Thinking about your physical health, for how many days in the week/month after the Incident did poor physical health keep you from doing your normal activities, such as self-care, work, or recreation? (Note to Survey Developer: change timeframe based on exposure period and time since incident)
_________days
Thinking about your physical health the week/month before the Incident and what it has been like in the past days/week/month. Would you say your physical health in the past days/week/month is… (Note to Survey Developer: change timeframe based on exposure period and time since incident)
Much better
Slightly better
About the same
Slightly worse
Much worse
What physical health resources are you using, or plan to use? ___________________________________
Don’t use any
Unsure
What physical health resources do you need? ___________________________
Don’t want any
Unsure
Mental Health Symptoms
Notes for online survey tool development: Apply
branching logic in the specified questions below: ONLY when
‘yes’ is selected for the following question: ‘Do
you feel you have the mental health resources you need to cope
with impacts of the Incident?’, make the following question
visible: What
mental
health resources are you
using, or plan to use? Remove
‘If yes,’ ONLY when
‘no’ is selected for the following question: ‘Do
you feel you have the mental health resources you need to cope
with impacts of the Incident?’, make the following question
visible: what
mental
health resources do you
need? Remove
‘If no,’
You will now be asked a few questions about your mental health related to the Incident. After an event like (insert incident), people may have strong and lingering reactions. It is natural to feel stress, anxiety, grief, and worry during and after events like this. These questions ask about your feelings before and during the recent (insert incident). There are no right or wrong answers. Every person will have different feelings. If you are struggling to cope, there are many ways to get help. Call your healthcare provider if stress gets in the way of your daily activities for several days in a row. You can also call the Disaster Distress Helpline: call or text 1-800-985-5990 (for Spanish, press “2”) to be connected with a trained counselor.
Anxiety Screener:
1. During the 2 weeks prior to the start of the Incident, how often were you bothered by the following problems? |
Not at all (0) |
Several days (+1) |
More than half the days (+2) |
Nearly every day (+3) |
Feeling nervous, anxious or on edge |
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Not being able to stop or control worrying |
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Total (add scores for each question): |
||||
2. Since the start of the Incident, how often have you been bothered by the following problems? |
Not at all (0) |
Several days (+1) |
More than half the days (+2) |
Nearly every day (+3) |
Feeling nervous, anxious or on edge |
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Not being able to stop or control worrying |
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Total (add scores for each question): |
||||
(Note to Survey Developer: Adapted Validated Shortform Screener for Anxiety (GAD-2). CODING NOTES – Interpretation of GAD-2: A score of 3 points is the preferred cut-off for identifying possible cases and in which further diagnostic evaluation for generalized anxiety disorder is warranted. Using a cut-off of 3 the GAD-2 has a sensitivity of 86% and specificity of 83% for diagnosis generalized anxiety disorder. Reference: Kroenke K, Spitzer RL, Williams JB, Monahan PO, Löwe B. Anxiety disorders in primary care: prevalence, impairment, comorbidity, and detection. Ann Intern Med. 2007;146:317-25.)
3. If you have recently experienced these symptoms, do you feel these symptoms are related to the incident?
Not at all
Somewhat
Mostly
Completely
I have not recently experienced these symptoms
Depression Screener:
4. During the 2 weeks prior to the start of the Incident, how often were you bothered by the following problems? |
Not at all (0) |
Several days (+1) |
More than half the days (+2) |
Nearly every day (+3) |
Little interest or pleasure in doing things |
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Feeling down, depressed, or hopeless |
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Total (add the scores for each question): |
||||
5. Since the start of the Incident, how often have you been bothered by the following problems? |
Not at all (0) |
Several days (+1) |
More than half the days (+2) |
Nearly every day (+3) |
Little interest or pleasure in doing things |
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Feeling down, depressed, or hopeless |
|
|
|
|
Total (add the scores for each question): |
||||
(Note to Survey Developer: Adapted Validated Shortform Screener for Depression (PHQ-2). CODING NOTES – Interpretation of PHQ-2: A PHQ-2 score ranges from 0-6. A score of 3 is the optimal cutpoint when using the PHQ-2 to screen for depression. If the score is 3 or greater, major depressive disorder is likely. For major depressive disorder, a score of 3 has 82.9% sensitivity and 90.0% specificity. For any depressive disorder, a score of 3 has 62.3% sensitivity and 95.4% specificity. Respondents with a score of 3 or higher should be further evaluated with the PHQ-9, other diagnostic instruments, or direct interview to determine whether they meet criteria for a depressive disorder. Reference: Kroenke K, Spitzer RL, Williams JB. The Patient Health Questionnaire-2: Validity of a Two-Item Depression Screener. Medical Care. 2003;41:1284-92.)
6. If you have recently experienced these symptoms, do you feel these symptoms are related to the incident?
Not at all
Somewhat
Mostly
Completely
I have not recently experienced these symptoms
Post-Traumatic Stress Disorder (PTSD) Screener:
Now we are going to ask about traumas you have had in the past, before the Incident, that were so frightening, horrible, or upsetting that they were still affecting you in the month before the Incident.
7. Were you experiencing any of the following in the month before the Incident related to a past trauma? |
Yes |
No |
Nightmares about it or thought about it when you did not want to? |
|
|
Went out of your way to avoid situations that reminded you of it? |
|
|
Were constantly on guard, watchful, or easily startled? |
|
|
Felt numb or detached from others, activities, or your surroundings? |
|
|
8. After the Incident, thinking about past and current traumas, did you experience any of the following: |
Yes |
No |
Nightmares about it or thinking about it when you did not want to? |
|
|
Going out of your way to avoid situations that remind you of it? |
|
|
Being constantly on guard, watchful, or easily startled? |
|
|
Feeling numb or detached from others, activities, or your surroundings? |
|
|
(Note to Survey Developer: Adapted Validated Shortform Screener for Post-Traumatic Stress Disorder (PC-PTSD) CODING NOTES – Interpretation: Three or more "yes" answers to each set of four questions represent a positive result for PTSD (78% sensitivity and 87% specificity compared to the Clinician Administered Scale for PTSD). Reference: Prins A, Ouimette P, Kimerling R, et al. The primary care PTSD screen (PC-PTSD): development and operating characteristics. Prim Care Psych. 2004;9:9-14.)
9. (If yes to anything in Q8) Do you feel these experiences are related to, or affected by, the Incident?
Not at all
Somewhat
Mostly
Completely
I have not recently experienced these symptoms
Mental Health Questions:
Thinking about your mental health, which includes stress, depression, and problems with emotions, for how many days in the days/week/month before the incident was your mental health NOT good? (Note to Survey Developer: change timeframe based on exposure period and time since incident)
___________days
Thinking about your mental health, which includes stress, depression, and problems with emotions, for how many days in the days/week/month during the incident was your mental health NOT good? (Note to Survey Developer: change timeframe based on exposure period and time since incident)
___________days
Thinking about your mental health, which includes stress, depression, and problems with emotions, for how many days in the days/week/month after the incident was your mental health NOT good? (Note to Survey Developer: change timeframe based on exposure period and time since incident)
___________days
Thinking about your mental health, for how many days in the week/month before the incident did poor mental health keep you from doing your normal activities, such as self-care, work, or recreation? (Note to Survey Developer: change timeframe based on exposure period and time since incident)
___________days
Thinking about your mental health, for how many days in the week/month during the incident did poor mental health keep you from doing your normal activities, such as self-care, work, or recreation? (Note to Survey Developer: change timeframe based on exposure period and time since incident)
___________days
Thinking about your mental health, for how many days in the week/month after the incident did poor mental health keep you from doing your normal activities, such as self-care, work, or recreation? (Note to Survey Developer: change timeframe based on exposure period and time since incident)
___________days
Thinking about your mental health the week/month before the incident would you say your mental health in the past week/month is… (Note to Survey Developer: change timeframe based on exposure period and time since incident)
Much better
Slightly better
About the same
Slightly worse
Much worse
What mental health resources have you used or plan to use?
_________________________
Don’t use any
Unsure
What mental health resources do you need?
_____________________________
Disability (Reference: National Health Statistics Reports, Number 161, August 9, 2021)
Do any of the following apply to you?
|
|
1. Are you blind or do you have serious difficulty seeing even when wearing glasses?
|
|
2. Are you deaf or do you have serious difficulty hearing?
|
|
3. Do you have serious difficulty walking or climbing stairs?
|
|
4. Because of a physical, mental, or emotional condition , do you have serious difficulty remembering, or making decisions?
|
|
5. Do you have difficulty dressing or bathing?
|
|
6. Because of a physical mental or emotional condition, do you have difficulty doing errands alone, such as visiting a doctor’s office or shopping?
|
|
7. Using your usual language, do you have difficulty understanding or being understood? |
|
Yes
8. Have any of
these difficulties caused a hardship for you during this Incident?
Yes
No
I
don’t know If Yes,
Explain_____________________________________________________________________
9. What resources do you use to cope with these difficulties during the Incident?_
Don’t use any
Unsure
10. What resources you need to cope with these difficulties arising from the incident? _____________________________
Don’t want any
Unsure
.Medical Care
Notes for online survey tool development:
Apply
branching logic in the specified questions below: ONLY when
‘yes’ is selected for the following question: ‘Did
you receive medical care or a medical evaluation because of the
incident?’, make the following questions visible: Which of
the following reasons influenced your decision to seek medical
care? (Select all that apply.) Who did
you receive medical care from? (Select all that apply.) How did
you get to the hospital? If you had more than one hospital visit,
refer to your first visit. If aged
18 or older, read: To improve future responses, we try to
understand medical emergency response as thoroughly as possible.
Are you willing to let us get a copy of your medical records for
the medical treatment you received because of the incident? ONLY when
‘no’ is selected for the following question: ‘Did
you receive medical care or a medical evaluation because of the
incident?’, make the following questions visible: Why
didn’t you seek medical care? (Select all that apply.) Remove “à
Go to Question 3” from the answer
choices of question: “Did you receive medical care or a
medical evaluation because of the incident?”
You will now be asked a few questions about illnesses you have and the kinds of medicines you used.
1. Are you covered by health insurance?
a) Yes
b) No
c) Prefer not to answer
d) Unsure
2. Did you receive medical care or a medical evaluation because of the incident?
Yes à Go to Question 4
No
3. Why didn’t you seek medical care? (Select all that apply.)
Did not have symptoms
Symptoms were not bad enough
Don’t like to go to the doctor
Didn’t want to take time
Worried about how to pay for the medical visit
Worried about losing job
Other (Please specify): ______________________________________________
Unsure
For individuals who did not seek medical care, go to the next module.
Which of the following reasons influenced your decision to seek medical care? (Select all that apply.)
You were given instructions to seek medical care
You experienced health problems or symptoms you thought/think are related to the Incident
You were worried about possible health problems associated with the Incident
You wanted to document your potential exposure
Other, please specify:_________________________________________________________________
Who did you receive medical care from? (Select all that apply.)
Assessed on the scene by an EMT or paramedic and released
Assessed at a hospital/emergency room and released
Assessed by a primary care doctor or other medical professional and released
Admitted to the hospital
Number of nights hospitalized _________
Admitted to the intensive care unit (ICU)
Number of nights spent in the ICU ___________
How did you get to the hospital? (If you had more than one hospital visit, refer to your first visit.)
EMS/Ambulance
I
drove myself
Driven
by relative, friend, or acquaintance
Other
(Please
specify):
To improve future responses, we try to understand medical emergency response as thoroughly as possible. Are you willing to let us get a copy of your medical records for the medical treatment you received because of the Incident?
Yes
à
Please
provide additional medical release consent
form
No
Medical History
You will now be asked a few questions about illnesses you may have had and the kinds of medicines you may have used.
1. Prior to the incident, have you ever been told by a doctor or other health care provider that you have or had any of the following medical conditions?
Medical History |
Responses |
Medical History |
Responses |
Anxiety or depression |
|
High blood pressure/hypertension |
|
Asthma |
|
Immune disorders such as lupus, rheumatoid arthritis, eosinophilic esophagitis or HIV |
|
Severe allergies (requiring an EpiPen) |
|
Neurobehavioral conditions (ADD, ADHD, Autism spectrum disorder, down syndrome, learning or intellectual disability, speech/language disorder) |
|
Cancer |
_______________________________
|
Autoimmune disease (such as Type 1 Diabetes, Celiac, or Juvenile Idiopathic Arthritis) |
|
Chronic obstructive pulmonary disease (COPD) or emphysema |
|
Post Traumatic Stress Disorder (PTSD) |
|
Diabetes (type 2) |
|
Neurological conditions such as Parkinson’s disease, or multiple sclerosis, or ALS |
_______________________________
|
GERD (Reflux) |
|
Cystic fibrosis |
|
Heart conditions, such as myocardial infarction or congestive heart failure |
|
Stroke |
|
Dependence disorder (alcohol, drugs) |
|
Blood disorders (such as Sickle Cell Disease, Thalassemia, or Hemophilla) |
|
Birth defect such as Cerebral Palsy |
|
Cystic fibrosis |
|
Epilepsy or seizure disorder |
|
Other |
Yes (Please specify) _______________________________ No Unsure |
2. Prior to the incident, were you taking any medication because of a health condition? This includes medication prescribed by a health care provider and those you might have gotten without a prescription from stores, pharmacies, friends, or relatives.
Yes
Please specify
No
Don’t Know
3. Prior to the incident, were you taking any medication because of difficulties with your emotions, concentration, or behavior?
Yes
Please specify
No
Don’t Know
4. Have you smoked at least 100 cigarettes in your ENTIRE LIFE?
Yes
No
Don’t know/refused
5. Do you currently smoke tobacco products (cigarettes, cigars, or pipes) ?
Daily
Less than daily
Not at all
Don’t know/refuse
6. Do you currently use electronic cigarettes or any other vaping device?
Daily
Less than daily
Not at all
Don’t know/refused
(Note to survey developers: Smoking questions adapted from Global Adult Tobacco Survey (GATS) and the NHIS Questionnaire)
Notes for online survey tool development:
These
questions will appear in the “Medical History” section
only if “Female” is selected in the “Participant
Information” section.
Apply
branching logic in the specified questions below:
Only when ‘yes, and I am still pregnant’ is selected
for the question: “Were you pregnant at the time of the
Incident?”, make the following questions visible:
What is your estimated due date?
Only when ‘no is selected for the question: “Were you
pregnant at the time of the Incident?”, make the following
questions visible:
Do you feel you had difficulty becoming pregnant since the
Incident?
Have you become pregnant since the Incident?
Only when ‘yes, and I am still pregnant’ is selected
for the question: “Were you pregnant at the time of the
Incident?” or when ‘yes’ is selected for the
question: “Have you become pregnant since the Incident?”,
make the following questions visible:
Did you give birth (including stillbirths) in the past 12 months?
Did you have any health problems during your pregnancy (check all
that apply)?
This series of questions refers to your first infant.
Only when ‘yes’ is selected for the question: “Did
you give birth (including stillbirths) in the past 12 months?”,
make the following answer choices visible:
What was the date of birth?
Did you have multiples?
Maternal
and Health Child Questions
Apply branching logic in the specified questions below:
Only when ‘yes, and I am still pregnant’ is selected for the question: “Were you pregnant at the time of the Incident?”, make the following questions visible:
What is your estimated due date?
Only when ‘no is selected for the question: “Were you pregnant at the time of the Incident?”, make the following questions visible:
Do you feel you had difficulty becoming pregnant since the Incident?
Have you become pregnant since the Incident?
Only when ‘yes, and I am still pregnant’ is selected for the question: “Were you pregnant at the time of the Incident?” or when ‘yes’ is selected for the question: “Have you become pregnant since the Incident?”, make the following questions visible:
Did you give birth (including stillbirths) in the past 12 months?
Did you have any health problems during your pregnancy (check all that apply)?
This series of questions refers to your first infant.
Only when ‘yes’ is selected for the question: “Did you give birth (including stillbirths) in the past 12 months?”, make the following answer choices visible:
What was the date of birth?
Did you have multiples?
These questions will appear in the “Medical History” section only if “Female” is selected in the “Participant Information” section.
The following questions ask about potential pregnancies and what you experienced during your pregnancy.
Were you pregnant at the time of the Incident?
No
I don’t know
Prefer not to answer
Yes, and I am still pregnant
2. [IF YES to Q1]
What is your estimated due date? __ __/__ __/ __ __ __ __
M M/ D D / Y Y Y Y
3. [IF NO, to Q1] Do you feel you had difficulty becoming pregnant since the Incident?
Yes
No
I don’t know
Prefer not to answer
NA
4. [If no, to Q1] Have you become pregnant since the Incident?
Yes
No
I don’t know
Prefer not to answer
NA
IF YES to “WERE YOU PREGNANT” or “HAVE YOU BECOME PREGNANT”?
5. Did you give birth (including stillbirths) since the incident?
No
Yes
[If YES] what was the date of birth? __ __/__ __/ __ __ __ __
M M/ D D / Y Y Y Y
[If YES] Did you have multiples?
No
Yes, how many? ___________
6. Did you have any health problems during your pregnancy? (Select all that apply.)
Miscarriage
Pre-eclampsia
High blood pressure
Diabetes
Gestational diabetes
Vaginal bleeding
Depression
Premature labor
Excessive weight gain
Hyperemesis (extreme vomiting)
Difficulty gaining weight
Stillbirth/infant died
Other _______________________________________________
None of the above
7. This series of questions refers to your first infant.
Did the infant have any problems at birth? (Select all that apply.)
Preterm (infant born before 37 completed weeks of gestation)
Low birth weight (infant born weighing less than 2,500 grams or 5 pounds and 8 ounces)
Congenital defects. Please describe______________
Other___________
No problems at birth
Delivery method
Vaginal
C-section
Primary method of infant feeding
Breast
Formula
Has the infant had any of the following (Select all that apply.):
Immune system concerns – difficulty fighting infections
Developmental delays
Heart problems
Respiratory issues such as reactive airway disease
Other ________
None of the above
Notes for online survey tool development: general module survey:
Apply
branching logic in the specified questions below:
ONLY when
‘yes’ is selected for the following question: ‘Do
you have an email address where you can be reached?’, make
the following questions visible:
What is
your email address?
Remove “à
Go to Q8” from the answer choices of
question: “Do you have an email address where you can be
reached?”
Communication and Needs
Apply branching logic in the specified questions below:
ONLY when ‘yes’ is selected for the following question: ‘Do you have an email address where you can be reached?’, make the following questions visible:
What is your email address?
Remove “à Go to Q8” from the answer choices of question: “Do you have an email address where you can be reached?”
Now we would like to ask you a few questions about the communication you may have received regarding the incident.
How were you first notified about the Incident? (Select only one)
Directly from person in authority (i.e. police, firefighter, Hazmat official, supervisor)
TV
Radio
Two-way radio
Newspaper
Relative/friend/neighbor/
Coworker
Website
Social Media
Reverse 911 call
Phone call
Text message on a cell phone
Email
Community Meeting
Other, Specify: ____________________________________________________________
How soon after the Incident did you receive instructions?
______hours _______minutes
Was the information Sufficient/helpful?
Yes
No
Don’t know/refused
How did you receive additional/follow-up information about the status of the incident? (Select all that apply.)
Directly from person in authority (i.e. police, firefighter, Hazmat official, supervisor)
TV
Radio
Two-way radio
Newspaper
Relative/friend/neighbor/
Coworker
Website
Social Media
Reverse 911 call
Phone call
Text message on a cell phone
Email
Community Meeting
Other, Specify: ____________________________________________________________
How soon after the initial notification about the Incident did you begin receiving follow-up/additional notifications/instructions?
______hours _______minutes
Was the information helpful?
Yes
No
Partially
Don’t know/refused
In the future, what are the best ways for local authorities or the health department to reach you with information regarding an incident? (Select all that apply.)
TV
Radio
Two-way radio
Newspaper
Website
Social Media
Phone call
Text message on a cell phone
Email
Community Meeting
Other, Specify: ____________________________________________________________
As a result of this incident, are you personally in need of anything? (Select all that apply.)
Medicine or medical supplies
Medical care
Mental health care
Water
Shelter
Food
Utilities
Transportation
Other, specify _________________________________
Don’t know/refused
Other household exposures
During the time of the Incident, did you own, foster or board any pets (dogs, cats, birds, fish, reptiles etc.)? (If yes, later you will be asked more questions about pets in your care)
Yes
No
N/A unknown
During the Incident, did you own, foster, or board any livestock animals (cattle, goats, pigs, poultry, etc.)? (If yes, later you will be asked more questions about livestock in your care)
Yes
No
N/A unknown
In order to accurately evaluate the impact of the Incident, we are trying to survey as many people as possible who were in the affected area.
Are you the parent/guardian of a child under 18 years who may have been exposed to the incident (If yes, later you will be prompted to complete questions for your children).
Child Questions
These questions will only appear if “yes” is selected for the questions “Are you the parent/guardian of a child under 18 years who may have been exposed to the contaminated water?” in the “Demographic And Contact Information” section of the survey.
Location And Exposure Information
Notes
for online survey tool development:
Apply
branching logic in the specified questions below:
ONLY
when ‘Same as home address above’ is selected for the
question: “While you were in the affected area during the
incident, did you smell an odor you thought was caused by the
incident?”, hide the following: “While you were in the
affected area during the incident, did you smell an odor you
thought was caused by the incident?”, hide the following: Street:
City: County: State: Zip: If
you are not sure of the exact address, please provide as much
location information as possible (i.e. closest landmark, building
name, cross streets). Under
question: “Do you think you were in contact with
contaminants?” Make
“If yes, why do you think/know you were contaminated?”
visible ONLY when ‘Yes’ is selected Remove
‘If yes,’ ONLY
when ‘yes’ is selected for the question: “While
you were in the affected area during the incident, did you smell
an odor you thought was caused by the incident?”, make the
following questions visible: For
how long did you smell this odor? How
intense was the smell? What
would you say the odor smelled like? (Select all that apply) Did
you receive instructions to shelter in place?
ONLY when ‘yes’
is selected for the question: “Did you receive instructions
to shelter in place?”, make the following question visible: How
long did you shelter in place? Remove
(if yes, to 9) Did
you receive instructions to evacuate? ONLY
when ‘yes’ is selected for the question: “Did
you receive instructions to evacuate?”, make the following
question visible: Did
you evacuate from the affected area? Remove
(if yes, to 11) How
did you first learn you needed to shelter in place/evacuate? ONLY
when ‘yes’ is selected for the question: “Did
you evacuate from the affected area? “, make the
following question visible: How
long did you evacuate for? Remove
(if yes, to 11) At
approximately what time did you evacuate? If
you evacuated, did you take any pets with you? Only
when ‘yes, career responder’ is selected for the
question: Were you a responder (career or volunteer) in any way to
this incident, make the following question visible: If
you are a hospital worker, EMS worker, or other, were using any
types of PPE during this event?
Only
when ‘yes, volunteer responder is selected for the question:
Were you a responder (career or volunteer) in any way to this
incident, make the following question visible:
If
you are a volunteer firefighter through company responder, were
using any types of PPE
during this event?
These next few questions will ask about where your child was during the Incident and what protective measures were taken during the Incident to help us understand your child’s potential exposure.
1. Within the affected area, where did your child spend the most time during the Incident?
Same as home address above (Skip to next question)
Location name:_________________________________________________
Street: ________________________________________________________
City:______________________ County:________________________
State:_______________ ZIP:__________________
*If you are not sure of the exact address, please provide as much location information as possible (i.e. closest landmark, building name, cross streets). _____________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________
2. Referring to the question above, what was your child’s physical location during the Incident? (Select all that apply.)
Inside building
Outside
Inside a car/vehicle
Other ________________
3. How long was your child in the affected area during the Incident? (Note to Survey Developer: response choices may vary with specific incident.)
Less than an hour
1-5 hours
5-12 hours
13 hours -1 day
2-4 days
5 or more days
4. Do you think your child was in contact with contaminants?
Yes
If yes, why do you think/know your child was contaminated? ___________________________________
No
Unsure
5. While your child was in the affected area during the Incident, did they smell an odor they thought was caused by the Incident?
Yes
No
I don’t know
6. How intense was the smell?
Light
Moderate
Severe
7. What would your child say the odor smelled like? (Select all that apply.)
Gasoline
Rotten eggs
Chemical smell
Paint
Paint thinner
Car tires or asphalt
Bug spray
Sweet smell
Smoke
Sewage
Other, please specify:____________________________________________
8. Did your child receive instructions to shelter in place?
Yes
No
I don’t know
9. (If yes, to 8) How long did your child shelter in place? (Note to Survey Developer: response choices may vary with specific incident.)
They did not shelter in place
Less than an hour
1-5 hours
5-12 hours
1 day
2-4 days
5 or more days
10. Did your child receive instructions to evacuate?
Yes (Complete the remainder of this section.)
No (Go to the next section.)
I don’t know
N/A
11. Did your child evacuate from the affected area?
Yes, they evacuated
No, they did not evacuate
I don’t know
N/A
12. At approximately what date and time did your child evacuate?
____:_____
AM
PM
Hour Min
13. How long did your child evacuate for? (Note to Survey Developer: response choices may vary with specific incident.)
My child did not evacuate
Less than an hour
1-5 hours
5-12 hours
13 hours - 1 day
2-4 days
5 or more days
14. How did your child first learn they needed to shelter in place/evacuate?
Directly from person in authority (i.e. police, firefighter, Hazmat official, principal)
TV
Radio
Two-way radio
Newspaper
Relative/friend/neighbor
Teacher or classmate
Website
Social Media
Reverse 911 call
Phone call
Text message
Email
Community meeting
Other, Specify ________________________________________________________
15. While within the “affected area” (define) did your child wear personal protective equipment (PPE)? (Select all that apply.)
None
Skin protection (gloves/face shield/overalls/disposable gown/long sleeves/pants/boots)
Eye protection (protective shield/glasses/goggles)
Breathing/respiratory protection (mask/respirator/HEPA filters)
Other-specify the type of protection:
16. During the “exposure window” (define), did your child report to a physical location such as school or childcare facility within the “affected area” (define)? (see map)
Yes
No
Prefer not to answer
Unsure
17. Did your child need to stay home from school/childcare or miss school/childcare due to symptoms they experienced after the incident?
Yes
How many days did they miss?_________days
No
Unsure
18. Did your child need to modify their regular schoolwork due to symptoms they experienced after the incident?
Yes
How many days of modified school work did they need?_________days
No
Unsure
What, if anything, could have been done differently to improve the response from your child’s perspective?
Notes for online survey tool development: Apply
branching logic in the specified questions below: ONLY when
‘yes’ is selected for the following question: ‘Were
you told by a responder/healthcare professional that you were in
contact with contaminants?’, make the following questions
visible: Were your
measurements of exposure taken by an emergency responder or
healthcare worker (examples)? ONLY when
‘yes’ is selected for the following question: ‘Were
your measurements of exposure taken by an emergency responder or
healthcare worker (examples)?’, make the following questions
visible: Please
explain the measurements taken ONLY when
‘yes’ is selected for the following question: ‘Were
you decontaminated (i.e. your clothing was removed and/or your
body was washed, etc.)?’, make the following questions
visible: How were
you decontaminated?
Where
were you decontaminated? This question is asking for a geographic
location, not a place on their body.
At
approximately what time were you decontaminated?
Were you or your child told by a responder/healthcare professional that they were in contact with contaminants?
Yes
No
Unsure
Did your child have measurements of exposure taken by an emergency responder or healthcare worker? (Note: Insert measurement of exposure for specific investigation)
Yes
No
Unsure
Please explain the measurements taken: _________________________________________________
Was your child told to decontaminate?
Yes
No
Unsure
If yes, where on their body? ____________________________________________________________
Was your child decontaminated (i.e. clothing was removed and/or body was washed, etc.)?
Yes
No
Unsure
If yes, to 14. How was your child decontaminated? (Select all that apply.)
Clothing removal
Water
Soap and water
Other (Please specify): ___________________________________________________________________
Where was your child decontaminated? (This question is asking for a geographic location, not a place on the body.)
Community Resource Center (CRC)
Mobile decontamination unit
Emergency room (ER)
Other (Please specify):
At approximately what day and time was your child decontaminated?
Date ___/___ ___ /___ ___ ___ ___ (mm/dd/yyyy) Time ___:___ (am/pm)____:_____
Did your child go to a Community Resource Center (CRC)? (Note to Survey Developer: this question in generally only used for nuclear/radiologic events )
Yes
No
Unsure
If you went to a Community Resource Center (CRC) what tracking number did they give you?
_______________________________
Health Status after the Incident
Notes for online survey tool development:
Apply
branching logic in the specified questions below: ONLY when
‘New symptoms or conditions?’ or ‘Worsening of
your preexisting symptoms or conditions?’ are selected for
the following question: ‘Since the incident have you had’,
make the following questions visible: No, I
do not have this new or worsening symptom or condition Yes, I
am experiencing this new symptom or condition Yes, I
am experiencing worsening of this preexisting symptoms or
condition Yes, I am
still experiencing these symptoms/conditions No, I am
not still experiencing these symptoms/conditions
Introduction narrative: You will now be asked some questions about symptoms your child may have had that could be related to the Incident.
(Note to Survey Developer: This list should be narrowed down ahead of time with a toxicologist, physician, or other expert.)
29. Since the incident has your child had:
New symptoms or conditions?
Worsening of preexisting symptoms or conditions?
No new symptoms or conditions and no worsening of preexisting symptoms or conditions. (Skip to next section.)
If your child has had new symptoms or conditions or worsening of preexisting symptoms or conditions, please fill out the table provided below.
|
Has your child had any new symptoms or worsening of preexisting symptoms because of the Incident? |
At the time of completing this survey is your child still experiencing these symptoms? |
|||
Symptom |
No, they do not have this new or worse symptom skip to next symptom |
Yes, they are experiencing this new symptom |
Yes, they previously had this symptom, and it became worse after the Incident. |
Yes, they are still experiencing this symptom |
No, they are not still experiencing this symptom |
GENERAL |
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1.1 Fever |
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1.2 Chills |
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1.3 Generalized weakness |
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1.4 Body pain |
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1.5 Severe bleeding |
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EYES |
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2.1 Increased tearing |
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2.2 Irritation/pain/ burning of eyes |
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2.3 Blurred vision/double vision |
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2.4 Bleeding in eyes |
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2.5 Vision changes (floaters, blurry, loss) |
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EAR/NOSE/THROAT |
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3.1 Runny nose |
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3.2 Burning nose or throat |
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3.3 Nose Bleeds |
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3.4 Hoarseness |
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3.5 Increased salivation |
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3.6 Ringing in ears |
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3.7 Difficulty swallowing |
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3.8 Swollen neck |
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3.9 Pain in jaw |
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3.10 Odor on breath (Gasoline or other, specify) |
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3.11 Stuffy nose/sinus congestion |
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3.12 Increased congestion or phlegm |
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3.13 Hearing loss |
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NERVOUS SYSTEM |
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4.1 Headache |
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4.2 Dizziness or lightheadedness |
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4.3 Loss of consciousness/ fainting |
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4.4 Seizures or convulsions |
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4.5 Numbness, pins and needles, shooting pain, or funny feeling in arms or legs |
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4.6 Confusion |
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4.7 Difficulty concentrating |
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4.8 Difficulty remembering things |
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4.9 Concussion |
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4.10 Loss of balance |
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4.11 Involuntary muscle contractions (e.g., cramp, spasm, tremor) |
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MUSCLE/JOINT/BONES |
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5.1 Weakness of arms |
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5.2 Weakness of legs |
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5.3 Joint swelling |
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5.4 Muscle weakness |
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5.5 Muscle twitching |
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5.6 Tremors in arms or legs |
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5.7 Joint or body pain |
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5.8 Broken bone/fracture |
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5.9 Dislocation |
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5.10 Sprain or strain |
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5.11 Whiplash |
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PULMONARY (LUNGS) |
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6.1 Breathing slow |
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6.2 Breathing fast |
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6.3 Difficulty breathing/feeling out-of-breath |
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6.4 Coughing |
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6.5 Wheezing in chest |
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6.6 Bronchitis |
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6.7 Pneumonia |
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6.8 Burning/pain in lungs |
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6.9 Phlegm |
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CARDIOVASCULAR (HEART) |
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7.1 Chest tightness or pain/angina |
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7.2 Fluttering in the chest |
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7.3 Slow heart rate/pulse |
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7.4 Fast heart rate/pulse |
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7.5 Irregular heart rate |
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STOMACH/INTESTINES |
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8.1 Nausea |
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8.2 Non-bloody vomiting |
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8.3 Non-bloody diarrhea |
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8.4 Bloody vomiting |
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8.5 Blood in stool/diarrhea |
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8.6 Abdominal pain/stomach ache |
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8.7 Fecal incontinence or inability to control bowel movements |
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8.8 Bowel perforation |
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8.9 Acid reflux (gastric reflux/indigestion) |
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SKIN/Hair/Nails/Teeth |
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9.1 Irritation, pain, or burning of skin |
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9.2 Skin rash |
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9.3 Hives |
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9.4 Skin blisters |
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9.5 Bumps containing pus |
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9.6 Nail changes |
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9.7 Hair loss in area of rash |
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9.8 Hair loss |
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9.9 Dry or itchy skin |
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9.10 Sweating |
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9.11 Cool or pale skin |
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9.12 Skin discoloration |
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9.13 Poor wound healing |
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9.14 Petechiae/Pinpoint round spots |
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9.15 Blue coloring of ends of fingers/toes or lips |
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9.16 Lips turning blue |
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9.17 Abrasion/scrape |
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9.18 Bruise |
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9.19 Cut |
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9.20 Acid reflux (gastric reflux/indigestion) |
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9.21 Dental issues (mouth sores, tooth decay or pain) |
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KIDNEY/BLADDER/GENITAL |
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10.1 Urinary incontinence or dribbling pee |
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10.2 Inability to urinate or pee |
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10.3 Blood in urine |
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10.4 Painful/ burning urine |
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10.5 Increased urinary urgency |
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10.6 Menstrual irregularities |
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General Physical Health Questions:
Notes for online survey tool development:
Apply
branching logic in the specified questions below: ONLY when
‘yes’ is selected for the following question: ‘Do
you feel you have the physical health resources you need to cope
with impacts of the Incident?’, make the following question
visible: what
physical
health resources are you
using, or plan to use? Remove
‘If yes,’ ONLY when
‘no’ is selected for the following question: ‘Do
you feel you have the physical health resources you need to cope
with impacts of the Incident?’, make the following question
visible: what
physical
health resources do you
need? Remove
‘If no,’
30. Thinking about your child’s physical health (their body’s ability to function normally) for how many days in the days/week/month before the Incident was your child’s physical health NOT good? (Note to Survey Developer: change timeframe based on exposure period and time since incident)
_________days
31. Thinking about your child’s physical health (theirtthheir body's ability to function normally) for how many days in the days/week/month during the Incident was your child’s physical health NOT good? (Note to Survey Developer: change timeframe based on exposure period and time since incident)
_________days
32. Thinking about your child’s physical health (their body's ability to function normally) for how many days in the days/week/month after the Incident was your child’s physical health NOT good? (Note to Survey Developer: change timeframe based on exposure period and time since incident)
_________days
33. Thinking about your child’s physical health, for how many days in the days/week/month before the Incident did poor physical health keep your child from doing normal activities, such as self-care, school, or recreation? (Note to Survey Developer: change timeframe based on exposure period and time since incident)
_________days
34. Thinking about your child’s physical health, for how many days in the days/week/month during the Incident did poor physical health keep your child from doing normal activities, such as self-care, school, or recreation? (Note to Survey Developer: change timeframe based on exposure period and time since incident)
_________days
35. Thinking about your child’s physical health, for how many days in the days/week/month after the Incident did poor physical health keep your child from doing normal activities, such as self-care, work, or recreation? (Note to Survey Developer: change timeframe based on exposure period and time since incident)
_________days
36. Think about your child’s physical health the week/month before the Incident and what it has been like in the past week/month . Would your child say their physical health in the past week/month is… (Note to Survey Developer: change timeframe based on exposure period and time since incident)
Much better
Slightly better
About the same
Slightly worse
Much worse
37. Do you feel your child has the physical health resources they need to cope with impacts of the Incident?
Yes
No
Unsure
38. If yes, what physical health resources are they using, or plan to use? ___________________________________
None used
unsure
39. If no, what physical health resources do they need? ___________________________
None needed
Unsure
Notes for online survey tool development: Apply
branching logic in the specified questions below: ONLY when
‘yes’ is selected for the following question: ‘Do
you feel you have the mental health resources you need to cope
with impacts of the Incident?’, make the following question
visible: What
mental
health resources are you
using, or plan to use? Remove
‘If yes,’ ONLY when
‘no’ is selected for the following question: ‘Do
you feel you have the mental health resources you need to cope
with impacts of the Incident?’, make the following question
visible: what
mental
health resources do you
need? Remove
‘If no,’
You will now be asked a few questions about your child’s mental health related to the Incident. After an event like (insert incident), people may have strong and lingering reactions. It is natural to feel stress, anxiety, grief, and worry during and after events like this. These questions ask about your child’s feelings before and during the recent (insert incident). There are no right or wrong answers. Every person will have different feelings. If your child is struggling to cope, there are many ways to get help. Call your healthcare provider if stress gets in the way of your child’s daily activities for several days in a row. You can also call the Disaster Distress Helpline: call or text 1-800-985-5990 (for Spanish, press “2”) to be connected with a trained counselor.
40. During the 2 weeks prior to the start of the Incident, how often as your child bothered by the following problems? |
Not at all (0) |
Several days (+1) |
More than half the days (+2) |
Nearly every day (+3) |
Feeling nervous, anxious or on edge |
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Not being able to stop or control worrying |
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Total (add scores for each question): |
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41. Since the start of the incident, how often has your child been bothered by the following problems? |
Not at all (0) |
Several days (+1) |
More than half the days (+2) |
Nearly every day (+3) |
Feeling nervous, anxious or on edge |
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Not being able to stop or control worrying |
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Total (add scores for each question): |
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(Note to Survey Developer: Adapted Validated Shortform Screener for Anxiety (GAD-2). CODING NOTES – Interpretation of GAD-2: A score of 3 points is the preferred cut-off for identifying possible cases and in which further diagnostic evaluation for generalized anxiety disorder is warranted. Using a cut-off of 3 the GAD-2 has a sensitivity of 86% and specificity of 83% for diagnosis generalized anxiety disorder. Reference: Kroenke K, Spitzer RL, Williams JB, Monahan PO, Löwe B. Anxiety disorders in primary care: prevalence, impairment, comorbidity, and detection. Ann Intern Med. 2007;146:317-25.)
42. If your child has recently experienced these symptoms, do they feel these symptoms are related to the Incident?
Not at all
Somewhat
Mostly
Completely
My child has not recently experienced these symptoms
43. During the 2 weeks prior to the start of the incident, how often was your child bothered by the following problems? |
Not at all (0) |
Several days (+1) |
More than half the days (+2) |
Nearly every day (+3) |
Little interest or pleasure in doing things |
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Feeling down, depressed, or hopeless |
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Total (add the scores for each question): |
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44. Since the start of the incident, how often has your child been bothered by the following problems? |
Not at all (0) |
Several days (+1) |
More than half the days (+2) |
Nearly every day (+3) |
Little interest or pleasure in doing things |
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Feeling down, depressed, or hopeless |
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Total (add the scores for each question): |
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(Note to Survey Developer: Adapted Validated Shortform Screener for Depression (PHQ-2). CODING NOTES – Interpretation of PHQ-2: A PHQ-2 score ranges from 0-6. A score of 3 is the optimal cutpoint when using the PHQ-2 to screen for depression. If the score is 3 or greater, major depressive disorder is likely. For major depressive disorder, a score of 3 has 82.9% sensitivity and 90.0% specificity. For any depressive disorder, a score of 3 has 62.3% sensitivity and 95.4% specificity. Respondents with a score of 3 or higher should be further evaluated with the PHQ-9, other diagnostic instruments, or direct interview to determine whether they meet criteria for a depressive disorder. Reference: Kroenke K, Spitzer RL, Williams JB. The Patient Health Questionnaire-2: Validity of a Two-Item Depression Screener. Medical Care. 2003;41:1284-92.)
45. If your child has recently experienced these symptoms, do they feel these symptoms are related to the incident?
Not at all
Somewhat
Mostly
Completely
My child has not recently experienced these symptoms
Post-Traumatic Stress Disorder (PTSD) Screener:
Now we are going to ask about traumas your child has had in the past, before the Incident, that were so frightening, horrible, or upsetting that they are affecting your child still, in the month before the Incident.
46. Was your child experiencing any of the following in the month before the Incident related to a past trauma? |
Yes |
No |
Child had nightmares about it or thought about it when they did not want to? |
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Child went out of their way to avoid situations that reminded them of it? |
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Child was constantly on guard, watchful, or easily startled? |
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Child felt numb or detached from others, activities, or surroundings? |
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47. After the Incident, thinking about past and current traumas, did your child experience any of the following: |
Yes |
No |
Child had nightmares about it or thinking about it when they did not want to? |
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Child going out of their way to avoid situations that remind them of it? |
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Child being constantly on guard, watchful, or easily startled? |
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Child feeling numb or detached from others, activities, or surroundings? |
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(Note to Survey Developer: Adapted Validated Shortform Screener for Post-Traumatic Stress Disorder (PC-PTSD) CODING NOTES – Interpretation: Three or more "yes" answers to each set of four questions represent a positive result for PTSD (78% sensitivity and 87% specificity compared to the Clinician Administered Scale for PTSD). Reference: Prins A, Ouimette P, Kimerling R, et al. The primary care PTSD screen (PC-PTSD): development and operating characteristics. Prim Care Psych. 2004;9:9-14.)
48. (If yes to anything in Q47) Does your child feel that these experiences are related to, or affected by, the Incident?
Not at all
Somewhat
Mostly
Completely
They have not recently experienced these symptoms
49. Thinking about your child’s mental health, which includes stress, depression, and problems with emotions, for how many days in the days/week/month before the incident was your mental health NOT good? (Note to Survey Developer: change timeframe based on exposure period and time since incident)
___________days
50. Thinking about your child’s mental health, which includes stress, depression, and problems with emotions, for how many days in the week/months during the incident was your mental health NOT good? (Note to Survey Developer: change timeframe based on exposure period and time since incident)
___________days
51. Thinking about your child’s mental health, which includes stress, depression, and problems with emotions, for how many days in the days/week/month after the incident was your mental health NOT good? (Note to Survey Developer: change timeframe based on exposure period and time since incident)
___________days
52. Thinking about your child’s mental health, for how many days in the week/month before the incident did poor mental health keep them from doing normal activities, such as self-care, school, or recreation? (Note to Survey Developer: change timeframe based on exposure period and time since incident)
___________days
53. Thinking about your child’s mental health, for how many days in the week/month during the incident did poor mental health keep them from doing normal activities, such as self-care, school, or recreation? (Note to Survey Developer: change timeframe based on exposure period and time since incident)
___________days
54. Thinking about your child’s mental health, for how many days in the week/month after the incident did poor mental health keep them from doing normal activities, such as self-care, school, or recreation? (Note to Survey Developer: change timeframe based on exposure period and time since incident)
___________days
55. Thinking about your child’s mental health the week/month before the incident would your child say their mental health in the past week/month is… (Note to Survey Developer: change timeframe based on exposure period and time since incident)
Much better
Slightly better
About the same
Slightly worse
Much worse
56. Does your child feel they have the mental health resources they need to cope with impacts of the Incident?
Yes
No
Unsure
57. If yes, what mental health resources are they using, or plan to use? ______________________
None used
Unsure
58. If no, what mental health resources do they need? _____________________________
None needed
Unsure
Notes for online survey tool development:
Apply
branching logic in the specified questions below: ONLY when
‘yes’ is selected for the following question: ‘Did
you receive medical care or a medical evaluation because of the
Incident?’, make the following questions visible: Which of
the following reasons influenced your decision to seek medical
care? (Select all that apply.) Who did
you receive medical care from? (Select all that apply.) How did
you get to the hospital? If you had more than one hospital visit,
refer to your first visit. If aged
18 or older, read: To improve future responses, we try to
understand medical emergency response as thoroughly as possible.
Are you willing to let us get a copy of your medical records for
the medical treatment you received because of the incident? ONLY when
‘no’ is selected for the following question: ‘Did
you receive medical care or a medical evaluation because of the
incident?’, make the following questions visible: Why
didn’t you seek medical care? (Select all that apply.) Remove “à
Go to Question 3” from the answer
choices of question: “Did you receive medical care or a
medical evaluation because of the incident?”
You will now be asked a few questions about medical care your child had related to the Incident.
59. Did your child receive medical care or a medical evaluation because of the incident?
Yes à Go to Question 3
No
60. Why didn’t your child seek medical care? (Select all that apply.)
Did not have symptoms
Symptoms were not bad enough
Don’t like to go to the doctor
Didn’t want to take time to take them
Worried about how to pay for the medical visit
Worried about falling behind in school work
Other (Please specify): ______________________________________________
Unsure
For individuals who did not seek medical care, go to the next module.
61. Which of the following reasons influenced the decision to seek medical care? (Select all that apply.)
Child was were given instructions to seek medical care
Child experienced health problems or symptoms we thought/think are related to the Incident
We were worried about possible health problems associated with the Incident
We wanted to document potential exposure
Other, please specify:_________________________________________________________________
62. Who did your child receive medical care from? (Select all that apply.)
Assessed on the seen by an EMT or paramedic and released
Assessed at a hospital/emergency room and released
Assessed by a primary care doctor or other medical professional and released
Admitted to the hospital
Number of nights hospitalized _________
Admitted to the intensive care unit (ICU)
Number of nights spent in the ICU ___________
63. How did your child get to the hospital? (If your child had more than one hospital visit, refer to your child’s first visit.)
EMS/Ambulance
I
drove my child
Driven
by relative, friend, or acquaintance
Other
(Please
specify):
64. To improve future responses, we try to understand medical emergency response as thoroughly as possible. Are you willing to let us get a copy of your child’s medical records for the medical treatment they received because of the Incident?
Yes
à
Please
provide additional medical release form consent
No
Medical History
You will now be asked a few questions about illnesses your child has and the kinds of medicines your child uses.
65. Prior to the Incident, have you ever been told by a doctor or other health care provider that your child has or had any of the following medical conditions?
Medical History |
Responses |
Medical History |
Responses |
Anxiety or depression |
|
High blood pressure/hypertension |
|
Asthma |
|
Immune disorders such as lupus, rheumatoid arthritis, eosinophilic esophagitis or HIV |
|
Severe allergies (requiring an EpiPen) |
|
Neurobehavioral conditions (ADD, ADHD, Autism spectrum disorder, down syndrome, learning or intellectual disability, speech/language disorder) |
|
Cancer |
_______________________________
|
Autoimmune disease (such as Type 1 Diabetes, Celiac, or Juvenile Idiopathic Arthritis) |
|
Chronic obstructive pulmonary disease (COPD) or emphysema |
|
Post Traumatic Stress Disorder (PTSD) |
|
Diabetes (type 2) |
|
Neurological conditions such as Parkinson’s disease, or multiple sclerosis, or ALS |
_______________________________
|
GERD (Reflux) |
|
Cystic fibrosis |
|
Heart conditions, such as myocardial infarction or congestive heart failure |
|
Stroke |
|
Dependence disorder (alcohol, drugs) |
|
Blood disorders (such as Sickle Cell Disease, Thalassemia, or Hemophilla) |
|
Birth defect such as Cerebral Palsy |
|
Cystic fibrosis |
|
Epilepsy or seizure disorder |
|
Other |
Yes (Please specify) _______________________________ No Unsure |
66. Prior to the incident, was your child taking any medication because of a health condition? This includes medication prescribed by a health care provider and those they might have gotten without a prescription from stores, pharmacies, friends, or relatives.
Yes
Please specify
No
Don’t Know
67. Prior to the incident, was this child taking any medication because of difficulties with their emotions, concentration, or behavior?
Yes
Please specify
No
Don’t Know
Disability (Reference: National Health Statistics Reports, Number 161, August 9, 2021)
68. Do any of the following apply to your child?
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1. Are they blind or do they have serious difficulty seeing even when wearing glasses?
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2. Are they deaf or do they have serious difficulty hearing?
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3. Do they have serious difficulty walking or climbing stairs?
|
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4. Because of a physical, mental, or emotional condition , do they have serious difficulty remembering, or making decisions?
|
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5. Do they have difficulty dressing or bathing?
|
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6. Because of a physical mental or emotional condition, do they have difficulty doing errands such as chores, alone?
|
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7. Using their usual language, do they have difficulty understanding or being understood? |
|
69.
Have any of these difficulties caused a hardship for them during this
Incident?
Yes
No
I
Don’t know If Yes,
Explain_____________________________________________________________________
70. What resources do they use to cope with these difficulties during the Incident?_
Don’t use any
Unsure
71. What resources do they need to cope with these difficulties arising from the incident? _____________________________
Don’t want any
Unsure
Communication and Demographics
Notes for online survey tool development: general module survey: Apply
branching logic in the specified questions below: ONLY when
‘yes’ is selected for the following question: ‘Do
you have an email address where you can be reached?’, make
the following questions visible: What is
your email address? Remove “à
Go to Q8” from the answer choices of
question: “Do you have an email address where you can be
reached?”
72. During emergency incident such as this Incident, there are often communication issues. Were there any communication issues that affected your child, such as you not being able to contact them or know what you needed to do for them?
Yes explain_________________________________
No, not communication issues
Unsure
We would now like to ask a few questions to gather general information so that we can better understand who we have collected information from.
73.What is your child’s legal name
________________________ , ________________ ___
Last First M.I.
74. What is your child’s date of birth? ____ /___ ___ /___ ___ ___ ___ (mm/dd/yyyy)
75. What is your child’s sex (select one)
Male
Female
Don’t know/refused
Other
76. What is your child’s race and/or ethnicity? (Select all that apply)
American Indian or Alaska Native (For example, Navajo Nation, Blackfeet Tribe of the Blackfeet Indian Reservation of Montana, Native Village of Barrow Inupiat Traditional Government, Nome Eskimo Community, Aztec, Maya, etc.)
Asian (For example, Chinese, Asian Indian, Filipino, Vietnamese, Korean, Japanese, etc.)
Black or African American (For example, African American, Jamaican, Haitian, Nigerian, Ethiopian, Somali, etc.)
Hispanic or Latino (For example, Mexican, Puerto Rican, Salvadoran, Cuban, Dominican, Guatemalan, etc.)
Middle Eastern or North African (For example, Lebanese, Iranian, Egyptian, Syrian, Iraqi, Israeli, etc.)
Native Hawaiian or Pacific Islander (For example, Native Hawaiian, Samoan, Chamorro, Tongan, Fijian, Marshallese, etc.)
White (For example, English, German, Irish, Italian, Polish, Scottish, etc.)
77. What is your child’s current level of education?
Preschool
Elementary School
Middle School
High School
Post High School
Not currently enrolled in school
78. Do you agree to be contacted about this Incident in the future if we may want to check up on your child’s health and needs?
Yes
No
Notes for online survey tool development:
The responder
survey will only appear if “yes” is selected for the
question “Were you a responder (career and/or volunteer) in
any way to this incident?” in the “Location and
Exposure” section of the survey.
Apply
branching logic in the specified questions below:
If a role is
checked allow for the number of years to be filled in.
Responder Questions
Apply branching logic in the specified questions below:
If a role is checked allow for the number of years to be filled in.
Only ask these questions if “yes” is selected for the question “Were you a responder (career and/or volunteer) in any way to this incident?” in the “Location and Exposure” section of the survey.
These next few questions will ask about your role throughout the incident. This will help us understand your potential exposure better.
1. What was your role during the response to the incident? (Select all roles that apply and add years in that role.)
|
_____years |
|
_____years |
|
_____years |
|
_____years |
|
_____years |
|
_____years |
|
_____years |
|
_____years |
|
_____years |
|
_____years |
2. Are you a contractor or self-employed?
Yes, contractor
Yes, self-employed
No
3. With which agency or local government did you respond with during the incident? (Note: Modify list and fill in local agencies here.)
Government Agency
Military
Investigating Agencies
Local agency
Prefer not to answer
Unsure
Please specify other agency: ________________________
4. If firefighter was selected as a role, In what capacity do you currently work for the Fire Department?
Volunteer Firefighter
Career Firefighter
Both career and volunteer firefighter
Prefer not to answer
Unsure
5. In what state did your responding agency originate? (Please specify):__________________________
Prefer not to answer
Unsure
6. What date did you first respond to the incident?
___/___ ___ /___ ___ ___ ___ (mm/dd/yyyy)
7. What is the last day you worked as a responder for the incident? If currently working, please select today's date.
___/___ ___ /___ ___ ___ ___ (mm/dd/yyyy)
8. What were your job tasks or responsibilities as an incident responder?
_______________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________
9. Did you have a supervisory role during your response to the incident?
Yes
No
Prefer not to answer
Unsure
Exposure Assessment
The next 3 questions will ask about your time spent within the affected area. (Note to survey developer, insert map or area description.)
10. Between the start of the incident and the end of the evacuation order (Note: Fill in dates.),please estimate the total number of hours you spent working on response activities within the affected area? _________________
11. Between the start of the incident until the end of the evacuation order (fill in dates), how many total hours did you spend working on response activities outside the 1-mile radius (dotted line)? ________________
(Note for survey developer: change 1-mile radius to appropriate exposure zone for this incident and if no evacuation order appropriate exposure end date).
12. From the start of the response (fill in date) to present, please estimate the total number of hours you have spent working on the response to this incident? ___________
(Note for survey developer: change 1-mile radius for appropriate exposure zone for this incident)
13. Have you been part of a chemical spill or emergency response before?
(Note to survey developer: only one response should be accepted for this question)
Yes
No -skip to Q 15
Prefer not to answer-skip to Q 15
Unsure-skip to Q 15
14. If yes, how many chemical spills or emergency responses have you been involved in?_____
(Note to survey developer: this question should be asked if individuals selected “Yes” for the previous question)
15. In the course of your work on this response, have you had direct contact to potentially harmful chemicals/substances by the following routes? (Select all that apply) (Note to survey developer: individuals can select more than one option except if “No I did not” is selected)
Dermal (skin contact)
Inhaling
Swallowing
No I did not
16. In the course of your work, did you receive a reading (from a gas, particulate matter meter or radiation dosimeter) stating you were exposed to a chemical?
Yes
No
Prefer not to answer
Unsure
17. Do you know what chemical/substance(s) you may have been exposed to? (Note to survey developer: individuals should select one)
18. To the best of your knowledge, what are the names of the chemicals you may have been exposed to while you responded to the incident? (Note to survey developer: this question should be asked if individuals selected “Yes” in the previous question)
19. Did you come in contact with any of the following? (Select all that apply ) Smoke
Dust
Debris
Liquid
Vapor/gas
Radiation
None of the above
Other_(specify) _______________________
Prefer not to answer
Unsure
(Note to survey developer specify should only be available if individuals selected “other” in the previous question)
20. Please select the physical location where you spent the most time while working on response activities: (Note to survey developer: all individuals should answer this question)
At the site of the derailment
Incident command location
Residential areas
Other (specifcy) _______________________________
Prefer not to answer
Unsure
(Note to survey developer, specify should only be available for individuals who selected “other” for the previous question)
Notes for online survey tool development:
Apply
branching logic in the specified questions below:
Only when ‘Yes’ is selected for the question: “Were
you injured during your response to the Incident?”, make the
following questions visible:
All subsequent questions in the “injuries related to the
incident” section
Only when ‘Yes, more than one injury’ is selected for
the question: “Were you injured more than once during your
response to the Incident?”, make the following questions
visible:
Please list the dates of each injury
Only when ‘No, just one injury” is selected for the
question: “Were you injured more than once during your
response to the Incident?”, make the following questions
visible:
What date were you injured?
Only when ‘hospitalized’, ‘seen in an emergency
department, urgent care, outpatient, occupational health, or
in-house doctor’, ‘receive in-person care at another
healthcare facility’, or ‘consulted a healthcare
provider via phone/video conferencing’ are selected, make
the following questions visible:
Where did you receive medical treatment for your injury or
injuries?
How many days were you hospitalized?
Only when ‘Other’ is selected for the question: “Where
did you receive medical treatment for your injury or injuries?”,
make the following question visible:
Please specify where you received treatment:
The next set of questions will ask you about any possible injuries you may have sustained while responding to the Incident.
21. Were you injured during your response to the Incident?
Yes
No (skip to Q 23)
Prefer not to answer (skip to Q 23)
Unsure (skip to Q 23)
22.
Where on your body did you get injured? (Select all that apply)
Head, face, neck
Trunk
Arms
Hands
Legs
Feet
23. How were you injured? (Select all that apply):
Abrasion/Contusion Amputation
Body fluid splash
Burn (thermal/electric) Burn (chemical)
Crush Fracture
Heat Exhaustion Laceration/puncture Needle stick/sharps Poisoning Sprain/strain
Other (describe)
24. What is the highest level of healthcare you received to treat your injury or injuries?
Assessed on the seen by an EMT or paramedic and released
Assessed at a hospital/emergency room and released
Assessed by a primary care doctor or other medical professional and released
Admitted to the hospital
Number of nights hospitalized _________
Admitted to the intensive care unit (ICU)
Number of nights spent in the ICU ___________
I did not receive any health care to treat my injury or injuries
Prefer not to answer
Unsure
24.
Did you report your injury or injuries to your supervising agency or
someone else?
Yes
No
Prefer not to answer
Unsure
25.
To whom did you report your injury or injuries?
26. Is there any other information you would like to provide us regarding your injury?_________________________________________________________
Notes for online survey tool development:
Apply
branching logic in the specified questions below:
Only when ‘Always’ or ‘Sometimes’ is
selected for the question: “Other PPE”, make the
following question visible:
Please describe the other personal protective equipment used:
Personal
Protective Equipment
The next section will ask you about your personal protective equipment use.
27. While responding to the incident, how often did you use the following? (Note allow to fill in specify if select always or sometimes for eye protection or other PPE) |
Select one answer for each row |
Chemical protective gloves |
|
Standard fire protection gear (fire helmet, turnout pants and jacket, leather gloves, boots) |
|
Hazmat suit |
|
Hazmat coveralls |
|
Eye protection type (specify________) |
|
Mask or respirator (see image below for examples) |
|
Other PPE (specify________) |
|
sometimes
sometimes
always
28.From the photo above, please selected yes or no to the types of you have worn while working on the response to the inciden and answer the remaining questions for those you have worn (Select all that apply) (Note: this question should be asked if individuals selected “Always” or “Sometimes” for option 6 (mask or respirator) in the previous question, individuals should select all options that apply)
Type |
Worn |
Why did you wear it? |
Fit tested last 12 months? |
Cloth face mask |
|
|
N/A |
Disposable surgical mask |
|
|
N/A |
KN95 Mask |
|
|
N/A |
N95 disposable |
|
|
N/A |
Elastomeric half-mask respirator |
|
|
|
Elastomeric full facepiece respirator |
|
Other |
|
Loose fitting PAPR |
|
|
|
Tight fitting full facepiece PAPR |
|
|
|
Full facepiece SCBA |
|
|
|
PAPR full facepiece SCBA |
|
specify________________
|
|
Other specify ___________________ |
|
|
|
After finishing a shift, during your work on the response, how often did you shower before returning home? (Note: individuals should select only one response for this question)
Always
Sometimes
Never
Unsure
After finishing a shift, during your work on the response, how often did you conduct decontamination of your protective clothing in the field? (Note: individuals should select only one response for this question)
Always
Sometimes
Never
Unsure
After finishing a shift, during your work on the response, how often did you change into clean clothes before returning home? (clean clothes refer to the clothes under any gear or protective layer) (Note: individuals should select only one response for this question)
Always
Sometimes
Never
Unsure
Only when yes is selected for “Since the Incident have you
experienced a new onset or worsening of symptoms”, make the
following questions visible:
Did any of your health symptoms worsen or return when on-site at
the Incident conducting your response job duties?
What do you think caused your symptom(s)?
Only when anything but none is selected for the question: in the
Adult Physical Health symptoms section “What is the highest
level of healthcare you received to treat your symptoms?”,
make the following questions visible:
How many days after beginning work as a responder to the incident
did you first receive medical care because of the Incident?
What diagnosis were you given for the symptom(s) or health
effect(s)
Were you prescribed any medications or treatment for your symptoms
that began after beginning work as a responder to this Incident?
Only when ‘yes’ is selected for the question in the
Adults healthcare section: “Were you prescribed any
medications or treatment for your symptoms that began after
beginning work as a responder to this Incident?”, make the
following questions visible:
What is the name of the medicine or medicines you were prescribed?
If you can't remember, what was the medicine for?
What do you think caused your symptom(s)? (Note: this question should be asked if individuals selected any health system option (1-7) at the beginning of this section)
How many days after beginning work as a responder to the Incident did you first receive medical care because of the Incident? (Note: this question should be asked if individuals selected Options 1 through 6 from the previous question or for the question on highest healthcare received for injuries)
Less than 24 hours after beginning work as a responder
1-2 days after beginning work as a responder
3-5 days after beginning work as a responder
6 days or longer after beginning work as a responder
I did not seek medical care because of the Incident
Prefer not to answer
Unsure
What diagnosis were you given for the symptom(s) or health effect(s)? (Note: this question should be asked if individuals selected Options 1 through 6 from the previous question regarding highest level of healthcare)
Were you prescribed any medications or treatment for your symptoms that began after beginning work as a responder to this Incident? (Note: this question should be asked if individuals selected Options 1 through 6 from the previous question or for the question on highest healthcare received for injuries)
Yes
No
Prefer not to answer
Unsure
What is the name of the medicine or medicines you were prescribed? If you can't remember, what was the medicine for? (Note: this question should be asked if individuals selected “Yes” from the previous question)_________________________________________________
Did the doctor or healthcare provider tell you that your symptom(s) were related to your work as a responder on this Incident? Were you prescribed any medications or treatment for your symptoms that began after beginning work as a responder to this incident? (Note: this question should be asked if individuals selected Options 1 through 6 from the previous question on highest healthcare received)
Yes
No
Prefer not to answer
Unsure
Notes for online survey tool development:
Apply branching
logic in the specified questions below:
Only when ‘yes’ is selected for the question: “Have
you been part of a chemical spill or emergency response before?”,
make the following question visible:
How many chemical spills or emergency responses have you been
involved in
Notes for online survey tool development:
Apply branching
logic in the specified questions below:
Only when ‘no’ is selected for the question: “Is
being a responder your primary job?”, make the following
question visible:
Which of the following best describes your work arrangement for
your primary job?
Only when ‘You work in a "permanent" salaried’
is selected for the question: “Which of the following best
describes your work arrangement for your primary job?”, make
the following answer choices NOT visible:
You work for a temp agency
You work as a freelance worker
You work as an independent contractor
You work as an independent consultant
Only when ‘You work in a "permanent" hourly
position’, is selected for the question: “Which of the
following best describes your work arrangement for your primary
job?”, make the following answer choices NOT visible:
You work for a temp agency
You work as an independent contractor
Only when ‘Yes,…” is selected for the question:
“Do you have another job?”, make the following question
visible:
How many total hours do you work in a typical week in your second
job?
The next set of questions asks about your primary job.
Is being a responder your primary job?
Yes
No
Prefer not to answer
Unsure
On average, how many hours per week do you work at your primary job? _______
On average since the incident, how many hours per week have you worked on activities not associated with the response to this Incident?____________
Are you a member of a union?
Yes
No
What is the name of your union?_________________________
Notes for online survey tool development:
Apply branching
logic in the specified questions below:
Only when ‘yes’ is selected for the question: “Since
you responded to the Incident, have you had at least one drink of
any alcoholic beverage such as beer, wine, a malt beverage, or
liquor?”, make the following question visible:
Since you first arrived on-site at the incident, has your alcohol
consumption:
Only when ‘no’ is selected for the question: “Is
being a responder your primary job?”, make the following
question visible:
Which of the following best describes your work arrangement for
your primary job?
Only when ‘You work in a "permanent" salaried’
is selected for the question: “Which of the following best
describes your work arrangement for your primary job?”, make
the following answer choices NOT visible:
You work for a temp agency
You work as a freelance worker
You work as an independent contractor
You work as an independent consultant
Only when ‘You work in a "permanent" hourly
position’, is selected for the question: “Which of the
following best describes your work arrangement for your primary
job?”, make the following answer choices NOT visible:
You work for a temp agency
You work as an independent contractor
Notes for online survey tool development:
Apply branching
logic in the specified questions below:
Only when ‘other training(s)’ is selected for the
question: “Have you ever received any of the following
trainings or training topics?”, make the following question
visible:
Please describe your other training(s):
Only when ‘other training(s)’ is selected for the
question: “Have you receive any of the following trainings or
training topics in the past 12 months”, make the following
question visible:
Please describe your other training(s) taken in the past 12
months:
Only when ‘no’ or ‘unsure’ are selected for
the question: “Do you feel that you were adequately prepared
to respond to this Incident?”, make the following question
visible:
If no or unsure, why not?
Is there equipment, training, or information you wish you had?
Please describe what and why
The following questions are about your responder training experience.
Have you ever received any of the following trainings or training topics? Please check off those you have EVER taken and for those that you have EVER taken whether you have taken them in the last 12 months.(Select all that apply): (Note: individuals should select all trainings and training topics that apply, unless they selected they did not have any of the listed trainings)
-
Training
Ever
Last 12 months
First Responder Awareness
First Responder Operations
Hazardous Materials Technician
HAZWOPER (24 hr)
HAZWOPER (40 hr+)
HAZWOPER annual refresher training (8 hr)
Cleaning and decontamination procedures for flammable and combustible materials
Proper handling and disposal of hazardous contaminants and containment of chemical spills
Hazard communication
Safety procedures during a chemical incident
Proper use of respiratory protection PPE
Proper use of other PPE
Other training(s) specify_____________________
I have not had any of the listed trainings
Unsure
Prefer not to answer
Please describe your other training(s) taken in the past 12 months: (Note: this question should be asked if individuals selected “other” for the previous question)
Do you feel that you were adequately prepared to respond to this incident?
Yes
No, explain_____________________
Prefer not to answer
Unsure explain_____________________
(Note: explain should open if individuals selected “No” or “Unsure” for the previous question)
Is there equipment, training, or information you wish you had? Please describe what and why. _________________________________(Note: this question should be asked if individuals selected “No” or “Unsure” for the previous question)
Household Pet Questions
Notes for online survey tool development:
These
questions will only appear if “yes” is selected for the
question “During the time of the Incident, did you own, foster
or board any pets (dogs, cats, birds, fish, reptiles etc.) AND
“Yes” for the question “since the Incident has
your pet (or pets) had worsening of a pre-existing or a new onset of
any symptoms?”
Apply branching
logic in the specified questions below: Only when
‘yes’ is selected for the question: “Were any of
your pets examined by a veterinarian after the incident?”,
make the following questions visible: Which of your
pets were seen by a veterinarian and how many of your pet were
seen by a veterinarian? Only when ‘no’
is selected for the question: “Were any of your pets examined
by a veterinarian after the incident?”, make the following
questions visible: If your pet/s
was not seen by a veterinarian, what contributed to this decision? Only when
‘yes’ is selected for the question: “Have any of
your pets died since the event?”, make the following
questions visible: Which animals
died? How did they
die? [Free text] Only when
‘yes’ is selected for the question: “Did you
evacuate any of your pet/s from their normal location because of
the incident?”, make the following questions visible: Which of the
following pet/s did you evacuate?
These questions will only appear if “yes” is selected for the question “During the time of the Incident, did you own, foster or board any pets (dogs, cats, birds, fish, reptiles etc.) AND “Yes” for the question “since the Incident has your pet (or pets) had worsening of a pre-existing or a new onset of any symptoms?”
General
At the time of the Incident which of the following types of pets, and how many did you own, foster, or board? (Select all that apply.)
Dogs
How many _______________
Cats
How many _______________
Birds
How many _______________
Fish
How many _______________
Reptiles
How many _______________
Other: [Free text]
How many _______________
Health
What type of pet has shown symptoms and what were their symptoms? (Select all that apply.)
Animal type with symptoms? |
How many with symptoms? |
Select symptoms |
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Were any of your pets examined by a veterinarian after the incident?
Yes
No
N/A, unknown
[IF YES THEN]
Which of your pets were seen by a veterinarian and how many of your pet were seen by a veterinarian? (Select all that apply.)
Dogs
How many _______________
Cats
How many _______________
Birds
How many _______________
Fish
How many _______________
Reptiles
How many _______________
Other: [Free text]
How many _______________
If your pet/s was not see by a veterinarian, what contributed to this decision? (Select all that apply.)
No symptoms
Symptoms were mild
Symptoms resolved
Pet died before veterinary visit
Financial constraints
Other [Free text]
Have any of your pets died since the event?
Yes
No
N/A, unknown
Which animals died? (Select all that apply.)
Dogs
How many _______________
Cats
How many _______________
Birds
How many _______________
Fish
How many _______________
Reptiles
How many _______________
Other: [Free text]
How many _______________
How did they die? [Free text] _____________________________________________________________
_____________________________________________________________________________________
Exposure
Where is your pet/s housed (where do they live)? *Note* depending on the type of exposure under investigation a barn or other inside dwelling besides a house may or may not be considered indoors. Make this clear in the question (e.g. Indoors is considered any indoor structure: house, barn, etc.; Indoors is considered only a house).
Indoor
Outdoor
Combined
Unknown
Other: [Free text]
Before the Incident, how many hours per day did your pet/s spend outdoors? *Note* depending on the type of exposure under investigation a barn or other inside dwelling besides a house may or may not be considered indoors. Make this clear in the question (e.g. Indoors is considered any indoor structure: house, barn, etc.); Indoors is considered only a house).
Exclusively indoors
< 2 hours
2-4 hours
>4 hours
Exclusively outdoors
Other [Free text]
During the exposure window, how many hours per day did your pet/s spend outdoors? *Note* depending on the type of exposure under investigation a barn or other inside dwelling besides a house may or may not be considered indoors. Make this clear in the question (e.g. Indoors is considered any indoor structure, house, barn, etc.); Indoors is considered only a house).
Exclusively indoors
< 2 hours
2-4 hours
>4 hours
Exclusively outdoors
Other [Free text]
Since the Incident how many hours per day does your pet/s spend outdoors? *Note* depending on the type of exposure under investigation a barn or other inside dwelling besides a house may or may not be considered indoors. Make this clear in the question (e.g. Indoors is considered any indoor structure, house, barn, etc.); Indoors is considered only a house).
Exclusively indoors
< 2 hours
2-4 hours
>4 hours
Exclusively outdoors
Other [Free text]
Before the Incident, what type of water sources did your animal/s drink from? (Select all that apply.)
Municipal water source
Private well
Outdoor bodies of water (ponds, streams, etc.)
Other [Free text]
During the Incident, what type of water source did your pet/s drink from? (Select all that apply.)
Municipal water source
Private well
Outdoor bodies of water (ponds, streams, etc.)
Other [Free text]
Since the Incident, what type of water source has your pet/s drank from? (Select all that apply.)
Municipal water source
Private well
Outdoor bodies of water (ponds, streams, etc.)
Other [Free text]
Did you evacuate any of your pet/s from their normal location because of the incident?
Yes
No
N/A, unknown
Which of the following pet/s did you evacuate? (Select all that apply.)
Dogs
How many _______________
Cats
How many _______________
Birds
How many _______________
Fish
How many _______________
Reptiles
How many _______________
Other: [Free text]
How many _______________
Livestock Questions
Notes for online survey tool development:
These
questions will only appear if “yes” is selected for the
question “During the Incident, did you own, foster, or board
any livestock animals (cattle, goats, pigs, poultry, etc.)?”
AND “Yes” for the question Since the Incident
have your livestock animal/s had worsening of a pre-existing or a
new onset of any symptoms?“
Apply branching
logic in the specified questions below: Only when
‘yes’ is selected for the question: “Were any of
your livestock examined by a veterinarian after the Incident?”,
make the following questions visible: Which of your
livestock were seen by a veterinarian? Only when ‘no’
is selected for the question: “Were any of your livestock
examined by a veterinarian after the Incident?”, make the
following questions visible: If your
[livestock type] was not see by a veterinarian, what contributed
to this decision Only when
‘yes’ is selected for the question: “Have any of
your livestock died since the event?”, make the following
questions visible: Which
livestock died? How did they
die? [Free text] Only when
‘yes’ is selected for the question: “Did you
evacuate any of your livestock from their normal location because
of the Incident?”, make the following questions visible: Which of the
following livestock did you evacuate?
These questions will only appear if “yes” is selected for the question “During the Incident, did you own, foster, or board any livestock animals (cattle, goats, pigs, poultry, etc.)?” AND “Yes” for the question Since the Incident have your livestock animal/s had worsening of a pre-existing or a new onset of any symptoms?“
Which of the following types of livestock do you own, foster, or board? (Select all that apply.) *Note* the use of “foster” will depend on the location and if the practice of fostering agriculture animals occurs.
Beef Cattle
How many _______________
Dairy Cattle
How many _______________
Horses
How many _______________
Sheep
How many _______________
Goats
How many _______________
Pigs
How many _______________
Poultry/Chicken
How many _______________
Other: [Free text]
How many _______________
Health
What type of livestock has shown symptoms and what were their symptoms? (Select all that apply.)
-
Animal type with symptoms?
How many with symptoms?
Select symptoms
Beef Cattle
1-1000
Difficulty breathing
Lethargy/lack of energy
Coughing
Vomiting
Sneezing
Loose stool or diarrhea
Eye or nose discharge
Inappetence or decreased eating
Other, specify _________________
Dairy Cattle
1-1000
Difficulty breathing
Lethargy/lack of energy
Coughing
Vomiting
Sneezing
Loose stool or diarrhea
Eye or nose discharge
Inappetence or decreased eating
Other, specify _________________
Horses
1-1000
Difficulty breathing
Lethargy/lack of energy
Coughing
Vomiting
Sneezing
Loose stool or diarrhea
Eye or nose discharge
Inappetence or decreased eating
Other, specify _________________
Sheep
1-1000
Difficulty breathing
Lethargy/lack of energy
Coughing
Vomiting
Sneezing
Loose stool or diarrhea
Eye or nose discharge
Inappetence or decreased eating
Other, specify _________________
Goats
1-1000
Difficulty breathing
Lethargy/lack of energy
Coughing
Vomiting
Sneezing
Loose stool or diarrhea
Eye or nose discharge
Inappetence or decreased eating
Other, specify _________________
Pigs
1-1000
Difficulty breathing
Lethargy/lack of energy
Coughing
Vomiting
Sneezing
Loose stool or diarrhea
Eye or nose discharge
Inappetence or decreased eating
Other, specify _________________
Poultry/Chicken
1-1000
Difficulty breathing
Lethargy/lack of energy
Coughing
Vomiting
Sneezing
Loose stool or diarrhea
Eye or nose discharge
Inappetence or decreased eating
Other, specify _________________
Other, please specify _________________
1-1000
Difficulty breathing
Lethargy/lack of energy
Coughing
Vomiting
Sneezing
Loose stool or diarrhea
Eye or nose discharge
Inappetence or decreased eating
Other, specify _________________
Other, please specify _________________
1-1000
Difficulty breathing
Lethargy/lack of energy
Coughing
Vomiting
Sneezing
Loose stool or diarrhea
Eye or nose discharge
Inappetence or decreased eating
Other, specify _________________
Were any of your livestock examined by a veterinarian after the Incident?
Yes
No
N/A, unknown
Which of your livestock were seen by a veterinarian? (Select all that apply.)
Beef Cattle
How many _______________
Dairy Cattle
How many _______________
Horses
How many _______________
Sheep
How many _______________
Goats
How many _______________
Pigs
How many _______________
Poultry/Chicken
How many _______________
Other: [Free text]
How many _______________
If your [livestock type] was not see by a veterinarian, what contributed to this decision? (Select all that apply.)
No symptoms
Symptoms were mild
Symptoms resolved
Pet died before veterinary visit
Financial constraints
Other [Free text]
Have any of your livestock died since the Incident?
Yes
No
N/A, unknown
Which livestock died? (Select all that apply.)
Beef Cattle
H ow many _______________
Dairy Cattle
How many _______________
Horses
How many _______________
Sheep
How many _______________
Goats
How many _______________
Pigs
How many _______________
Poultry/Chicken
How many _______________
Other: [Free text]
How many _______________
How did they die? [Free text]_____________________________________________________________
_____________________________________________________________________________________
Exposure
Is your home address the address where your livestock are located during the Incident?
Yes
No, please provide the address where your livestock were located during the Incident. ________________________________________________________________________
Where is your [livestock type] housed (where do they live)? *Note* depending on the type of exposure under investigation a barn or other inside dwelling besides a house may or may not be considered indoors. Make this clear in the question (e.g. Indoors is considered any indoor structure: house, barn, etc.; Indoors is considered only a dwelling with filtered central air circulation).
Indoor
Outdoor
Combined
Unknown
Other: [Free text]
Before the Incident, how many hours per day did your livestock spend outdoors? *Note* depending on the type of exposure under investigation a barn or other inside dwelling besides a house may or may not be considered indoors. Make this clear in the question (e.g. Indoors is considered any indoor structure, house, barn, etc.); Indoors is considered only a house).
Exclusively indoors
< 2 hours
2-4 hours
>4 hours
Exclusively outdoors
Other [Free text]
During exposure window for the Incident, how many hours per day did your livestock spend outdoors? *Note* depending on the type of exposure under investigation a barn or other inside dwelling besides a house may or may not be considered indoors. Make that clear in the question (e.g. Indoors is considered any indoor structure, house, barn, etc.); Indoors is considered only a house).
Exclusively indoors
< 2 hours
2-4 hours
>4 hours
Exclusively outdoors
Other [Free text]
After the Incident, how many hours per day does your livestock spend outdoors? *Note* depending on the type of exposure under investigation a barn or other inside dwelling besides a house may or may not be considered indoors. Make that clear in the question (e.g. Indoors is considered any indoor structure, house, barn, etc.); Indoors is considered only a house).
Exclusively indoors
< 2 hours
2-4 hours
>4 hours
Exclusively outdoors
Other [Free text]
Before the Incident, what type of water sources did your livestock drink from? (Select all that apply.)
Municipal water source
Private well
Outdoor bodies of water (ponds, streams, etc.)
Other [Free text]
During the exposure window for the Incident, what type of water source did your livestock drink from? (Select all that apply.)
Municipal water source
Private well
Outdoor bodies of water (ponds, streams, etc.)
Other [Free text]
During the exposure window for the Incident where was the water supplied to your livestock? (Select all that apply.)
Open to the air
Inside a barn and away from any plume
Other [Free text]
Since the Incident, what type of water source has your livestock drank from? (Select all that apply.)
Municipal water source
Private well
Outdoor bodies of water (ponds, streams, etc.)
Other [Free text]
Before the Incident, what was the source of feed/grazing for your livestock? (Select all that apply.)
Pasture
Hay from outside the area
Grain from outside the area
Other
During the Incident, what was the source of feed/grazing for your livestock? (Select all that apply.)
Pasture
Hay from outside the area
Grain from outside the area
Other
Since the Incident, what was the source of feed/grazing for your livestock? (Select all that apply.)
Pasture
Hay from outside the area
Grain from outside the area
Other
Did you evacuate any of your livestock from their normal location because of the Incident?
Yes
No
N/A, unknown
Which of the following livestock did you evacuate and how many? (Select all that apply.)
Beef Cattle
How many _______________
Dairy Cattle
How many _______________
Horses
How many _______________
Sheep
How many _______________
Goats
How many _______________
Pigs
How many _______________
Poultry/Chicken
How many _______________
Other: [Free text]
How many _______________
Community Resilience Question Bank
1.We are interested in hearing more about your experience. Would you be interested in answering a few questions where you can share your thoughts about your experience or being contacted by a member of our team to discuss your experience further?”
Yes I am willing to answer questions on my experience now
Yes, please have someone call me to discuss my experience further (Skip to conclusion)
I am not interested in discussing my experience, (Skip to conclusion
(Note: To maximize the opportunity to assess community resilience the survey developer should select one or more qualitative and one or more quantitative questions from each construct in the table below.)
Information and Communication |
||
Construct |
Quantitative Question |
Qualitative Question |
Narratives-
The community story around the incident |
|
|
Responsible Media-
Accurate and timely information and recommendations |
|
|
Skills and infrastructure –
Communication system infrastructure used to inform the public on Incident |
|
|
Trusted sources of information – in public outreach, and reflects the values and priorities of local populations |
|
|
Community Competence |
||
Construct |
Quantitative Question |
Qualitative Question |
Community action abilities to engage constructively in group process, resolve conflicts, collect and analyze data, and resist opposing or undesirable influences -the community’s ability to take action, |
|
|
Critical reflection and
problem- |
|
|
Flexibility and creativity |
|
|
Collective efficacy/Empowerment |
|
|
Political partnerships |
|
|
Social Capital individuals invest, access, and use resources embedded in social networks to gain returns |
||
Construct |
Quantitative Question |
Qualitative Question |
Social support – Actual assistance received |
|
|
Perceived (expected) social support |
|
|
Social embeddedness- informational ties, social relationships, including both the frequency and intensity of interactions. Encompasses benefits members receive from their social ties |
|
|
Organizational linkages and cooperation |
|
|
Citizen participation/ Leadership and roles- formal ties |
|
|
Sense of community- attitude of bonding- trust and belonging, with other members of one’s group or locale |
|
|
Attachment to place-an emotional connection to one’s neighborhood or city, somewhat apart from connections to the specific people who live there |
|
|
Economic Development |
||
Construct |
Quantitative Question |
Qualitative Question |
Fairness of risk and vulnerability to hazards- Economic resilience depends not only on the capacities of individual businesses but on the capacities of all the entities that depend on them and on which they depend |
|
|
Level and diversity of economic resources- diversity of economic resources
|
|
|
Equity of resource distribution- the fair and just allocation of resources within a community |
|
|
Community Resilience Question Bank
1.We are interested in hearing more about your experience. Would you be interested in filling out a few questions where you can share your thoughts about your experience or being contacted by a member of our team to discuss your experience further?”
Yes I am willing to answer questions on my experience now
Yes, please have someone call me to discuss my experience further (Skip to next section)
I am not interested in discussing my experience, (Skip to next section)
To maximize the opportunity to assess community resilience the survey developer should select one or more qualitative and one or more quantitative questions from each construct in the table below.
If questions will be asked without completing the full-length General ACE survey, consider collecting the demographics questions asked in the General ACE survey. These demographic data are important for analysis and reporting.
Information and Communication |
||
Construct |
Quantitative Question |
Qualitative Question |
Narratives-
The community story around the incident |
|
|
Responsible Media-
Accurate and timely information and recommendations |
|
|
Skills and infrastructure –
Communication system infrastructure used to inform the public on Incident |
|
|
Trusted sources of information – in public outreach, and reflects the values and priorities of local populations |
|
|
Community Competence |
||
Construct |
Quantitative Question |
Qualitative Question |
Community action abilities to engage constructively in group process, resolve conflicts, collect and analyze data, and resist opposing or undesirable influences -the community’s ability to take action, |
|
|
Critical reflection and
problem- |
|
|
Flexibility and creativity |
|
|
Collective efficacy/Empowerment |
|
|
Political partnerships |
|
|
Social Capital individuals invest, access, and use resources embedded in social networks to gain returns |
||
Construct |
Quantitative Question |
Qualitative Question |
Social support – Actual assistance received |
|
|
Perceived (expected) social support |
|
|
Social embeddedness- informational ties, social relationships, including both the frequency and intensity of interactions. Encompasses benefits members receive from their social ties |
|
|
Organizational linkages and cooperation |
|
|
Citizen participation/ Leadership and roles- formal ties |
|
|
Sense of community- attitude of bonding- trust and belonging, with other members of one’s group or locale |
|
|
Attachment to place-an emotional connection to one’s neighborhood or city, somewhat apart from connections to the specific people who live there |
|
|
Economic Development |
||
Construct |
Quantitative Question |
Qualitative Question |
Fairness of risk and vulnerability to hazards- Economic resilience depends not only on the capacities of individual businesses but on the capacities of all the entities that depend on them and on which they depend |
|
|
Level and diversity of economic resources- diversity of economic resources
|
|
|
Equity of resource distribution- the fair and just allocation of resources within a community |
|
|
Conclusion Statements
Notes for online survey tool development:
Only when ‘yes’ is selected for the question: “Would
you like us to mail you a copy of the completed survey?”,
make the following question visible:
Please provide the address where you would like to receive the
survey below:
Please take this opportunity to share any other concerns we have not yet asked about or add detail to concerns addressed earlier in the survey. Is there anything else you would like us know?
_______________________________________________________________________
Closing Statement:
That completes this survey. I would like to sincerely thank you for your time. From here, we’ll take your answers, along with those of other community members, and summarize them into recommendations for decision makers to help this community. Please share the survey with other adults who were int he area to take. Would you like us to mail you a copy of the completed survey?
a) Yes
b) No
Please provide the address where you would like to receive the survey below:
Same as home address
Other
Street: ________________________________________________________
City:______________________ County:________________________
State:_______________ ZIP:__________________
Date and time ended Date ___/___ ___ /___ ___ ___ ___ (mm/dd/yyyy) ___:___ (am/pm)
| File Type | application/vnd.openxmlformats-officedocument.wordprocessingml.document |
| File Title | ACE Toolkit – Adult Survey |
| Subject | SECTION I: ACE ADULT SURVEY - GENERAL SURVEY MODULE A: LOCATION/EXPOSURE |
| Author | CDC |
| File Modified | 0000-00-00 |
| File Created | 2024-10-07 |
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