Community Emergency Preparedness Survey

ID _ _ -_________

Community Emergency Preparedness Survey

Form Approved

OMB Control No.: 0920-1221

Expiration Date: 03/31/2020

Today’s Date: ____/____/2018

M M D D

Instructions: The information gathered from this survey will be used to understand the needs of community members in the event of an emergency. Please take a moment to fill out this survey. All responses are anonymous and confidential. This survey is voluntary. If you are not interested in participating, please return the blank survey to the survey staff. Thank you for your time.

First, please tell us a little about yourself:

1. Age: _____

2. Sex:  Female  Male

3. Zip Code of Residence: __________  Homeless

4. Ethnicity:

 Hispanic/Latino  Not Hispanic/Latino

5. Race (Check all that apply):

 American Indian or Alaska Native  Asian  Native Hawaiian or other Pacific Islander

 Black or African American  White

6. What best describes your education? (Check only one)

 Completed less than high school  High School Graduate or GED

 Some college, community college or trade school  College Graduate/Postgraduate

7. How would you describe your employment status? (Check all that apply)

 Full Time  Part Time  Self-employed  Unemployed  Retired  Disabled

8. What type of transportation do you usually use? (Check only one)

 Car  Bus Train  Bike  Walk  Motorcycle  Lyft/Uber  Other: __________________

9. How often do you take public transportation? (Check only one)

 Never  Rarely  Sometimes  Often

10. Do you speak a language other than English at home? (Check only one)

 Yes  No

11. If yes, what other language(s) do you speak at home? (For example, Korean, Spanish, etc.):

__________________________________________  Does Not Apply

12. Are you currently involved with any of the following types of community groups or organizations?

(Check all that apply)

Please go to the next page  

CDC estimates the average public reporting burden for this collection of information as 5 minutes per response, including the time for reviewing instructions, searching existing data/information sources, gathering and maintaining the data/information 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 Information Collection Review Office, 1600 Clifton Road NE, MS D-74, Atlanta, Georgia 30333; ATTN: PRA (0920-1221).

 Religious church/congregation  Service organization (Elks’, Rotary, etc.)  Social service agency  Other: _______________________

Now we would like to ask you a few questions about how you get healthcare services in Los Angeles County:

13. Where do you usually go to receive healthcare services (examinations, medications, etc.)? (Check only one)

 Primary Care Doctor’s Office  Hospital Emergency Room  Urgent Care  Health Clinic  Public Health Center  Prefer not to Answer  Other: _______________________

14. How far do you usually have to travel to reach these healthcare services? (Check only one)

 Less than 1 mile  Between 1 and 3 miles  Between 3 and 5 miles  More than 5 miles

Now we would like to ask you some questions about how you might get information during an emergency in your city:

15. In general, how do you prefer to access the internet? (Check only one)

 Home computer (like a laptop or desktop computer)

 Cell phone

 Tablet

 Computer at work

 Computer at the library/Public computer

 I do not use the internet

16. In an emergency, how would you anticipate getting news from emergency/government officials?

(Check all that apply)

 TV  Radio  Internet  Print News (newspaper)  Other__________________  Don’t know

Now we would like to ask you some questions about how you might respond during an emergency (like an earthquake) in your city:

17. During an emergency, what kind of resource(s) do you think you would need to stay home for 3 days?

(Check all that apply)

 Food  Water  Information  Housing  Transportation

 Prescription Medications  Other: _______________________

18. Would you be able to evacuate your city if asked to by emergency/government officials?

 Yes  No  Yes, if public transportation was provided  Don’t know

19. Would you be able to go to a location in the community to receive life-saving supplies (for example, medications)? (Check only one)

 Yes  No  Don’t know  Prefer not to answer

(If No, Don’t Know, or Prefer not to Answer, please skip to question 21.)

20. How would you travel to that location? (Check only one)

 Car  Bus Train  Bike  Walk  Motorcycle  Lyft/Uber  Other: __________________

21. During an emergency in your city, do you think you or someone in your household would want to speak to a mental health professional? (Check only one)

 Yes  No  Don’t know  Prefer not to Answer

22. In an emergency, could you see yourself going to any of these community-based organizations for help?

(Check all that apply)

 Religious church/congregation  Service organization (Elks’, Rotary, etc.)  Social service agency

 American Red Cross  Other: _______________________

CHECK ONE ANSWER PER QUESTION	Yes	No	I Don’t Know	I Don’t Wish To Share
Have you, or anyone in your household, taken special training for emergencies in your community (CERT, CPR, First Aid, etc.)?				
Do you know where the nearest hospital is to your home?				

Thank you for your participation! Please return the survey to the attendant.

Los Angeles County Dept. of Public Health, May 2018