Appx 4 HH Survey SAMPLE

Appendix 4: Household Survey

Form Approved

OMB No. 0923-XXXX

Exp. Date XX/XX/20XX

Interviewer__________ Household ID___________

Date _____________ Start time _____________ End time ______________

Cluster/Zone __________ Latitude _______________ Longitude ______________

Type of residence

Single family Multiple unit Mobile home Other ________________________

HOUSEHOLD SURVEY

Module A: Contact Information

1. What is your full name? __________________________________________________

2. What is your street address?

Street Apt

City __ State __ __ Zip Code:

3. What is the best telephone number to reach you in case we have questions about your survey? Please specify if this is a cellular phone, house phone, or work phone.

( __ __ __ ) __ __ __ ‑ __ __ __ __ Cell House Work

Module B: Demographics

1. How many people live in this residence? _____

How many are male? _____ How many are female? ­­­­­_____

2. How many people that live here are less than two years old? _____

217 years old? _____ 1864 years old? _____ More than 64 years old? _____

3. How many people in this household are of Hispanic, Latino, or Spanish origin? ­­­­_____

4. To which race do members of this household most identify? I will read a list of races. Please tell me how many people in the household identify as being that race. Record the number of people of each race described:

_____ Black _____ American Indian/Alaska Native

_____ White _____ Native Hawaiian or other Pacific Islander

_____ Asian

Public reporting burden of this collection of information is estimated to average 15 minutes per response, including the time for reviewing instructions, searching existing data sources, gathering and maintaining the 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 Reports Clearance Officer; 1600 Clifton Road NE, MS E-11 Atlanta, Georgia 30333; ATTN: PRA (0923-XXXX)

Module C: Location/Exposure and Communications

1. Was anyone home at any time between [Incident Date/Time] and [End Date/Time]?

Yes

No

2. After [the release] did you or anyone else in your household detect any unusual smells or tastes that you think were related to the incident?

Yes

No

3. How did your family first receive information or instructions about the incident? Check only one.

Noticed odor/saw chemical Directly from person in authority (police, firefighter)

Reverse 911 call to landline phone Reverse 911 call to cell phone

Call to landline phone Call to cell phone

TV Radio

Text message on a cell phone Social media (Facebook, Twitter)

Directly from another person (such as friend or relative)

Other (Please specify):______________________________________________________

4. As the incident progressed, how did you obtain information? Check all that apply.

Directly from person in authority (police, firefighter)

Reverse 911 call to landline phone Reverse 911 call to cell phone

Call to landline phone Call to cell phone

TV Radio

Text message on a cell phone Social media

Website Community meeting

Newspaper

Directly from another person (such as friend or relative)

Other (Please specify):______________________________________________________

5. Did your household receive instructions to shelter in place (meaning stay inside with the doors and windows closed) after [the release]?

Yes

No Go to Question C7

6. How did you receive instructions to shelter in place?

______________________________________________________________________

7. Were you given specific instructions about how to shelter in place?

Yes

No

8. What actions, if any, did you take to shelter in place?

______________________________________________________________________

______________________________________________________________________

9. Did your household evacuate after [the release]?

Yes

No Go to Question C13

10. Which day and at approximately what time did you evacuate?

____/____/______ ____:_____ AM PM

MM DD YYYY

11. When you evacuated, where did you go?

Shelter Hotel Friend’s/family’s house Other _________________________

12. When did you return home? ____/____/______ ____:_____ AM PM

MM DD YYYY

13. Do you have any pets?

Yes Go to Question C15

No

14. What kind of pets do you have and how many are there of each kind?

_____ Dog(s)

_____ Cats(s)

_____ Bird(s)

_____ Fish

_____ Other (specify):______________________________________________________

15. If you have pets, did you take all of them them with you when you evacuated?

Yes Go to Question C15

No

Took some but not all Go to Question C14

16. Which pets did you leave behind when you evacuated and what led to your decision to leave them?

______________________________________________________________________

______________________________________________________________________

Module D: Health Status

1. Within 24 hours of the incident, did you or anyone in your family have any symptoms of an illness?

Yes

No Go to Question E1

2. I will now read a list of symptoms that sometimes can follow exposure to [chemical]. Please tell me if anyone in the household who experienced each symptom within 24 hours of the release. Do not include a symptom that someone had before the release unless it got worse after the release. For each symptom that someone experienced, ask: How many people in the household experienced [symptom]?

Eye irritation Y N DK If yes, how many? ________

Nose or throat irritation Y N DK If yes, how many? ________

Coughing Y N DK If yes, how many? ________

Wheezing Y N DK If yes, how many? ________

Difficulty breathing Y N DK If yes, how many? ________

Headache Y N DK If yes, how many? ________

Dizziness or lightheadedness Y N DK If yes, how many? ________

Ringing of the ears Y N DK If yes, how many? ________

Nausea Y N DK If yes, how many? ________

Vomiting Y N DK If yes, how many? ________

Skin itching or burning Y N DK If yes, how many? ________

Skin rash Y N DK If yes, how many? ________

3. Were there any symptoms I didn’t ask about that members of the household experienced?

Yes (Please specify.)

No

______________________________________________________________________

______________________________________________________________________

Module E: Medical Care Received

1. Did you or anyone in your family receive medical care or a medical evaluation because of the incident?

Yes  Go to Question F3

No

2. Ask only if someone had symptoms: Why didn’t you or your family members seek medical care?

Symptoms were not bad enough    

Don’t like to go to the doctor

Didn’t want to take time

Worried about who would pay for the medical visit

Worried about losing job

Other (Please specify): ______________________________________________

Unsure

3. For each person who received medical care, please tell me the person’s name, where they received care, and the date. Please include medical evaluations by emergency medical services or EMTs, hospitals, and doctor’s offices.

Name	Where Received Care	Date

4. If a hospital was named, ask: Was [name] treated and released from the emergency department or hospitalized? If hospitalized, ask: How long was [he/she] hospitalized?

Name	Treated and Released	Hospitalized	Duration of Hospitalization

Module F: Needs

1. As a result of the incident, does your household need any of the following…

Read all choices to the respondent.

Medicines or medical supplies Yes No

Medical care Yes No

Water Yes No

Food Yes No

Shelter Yes No

Utilities Yes No

Anything else Yes No

If needs are identified in Question F1, obtain details on exactly what is needed.

Module G: Other Information

1. Is there anything else you want to tell us related to the [chemical] incident?

That completes this survey. I would like to sincerely thank you for your time. Be sure to record the end time on the first page of this survey.