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1. Have you ever personally been involved in an emergency situation before as a result of a: Hurricane? Earthquake? Tornado? Flood? Fire? Disease? Terrorist Attack? None Other
If Other:
2. Have you ever been in an emergency situation when YOU:
3. How likely do you think the following different emergency situations are to happen in our community in the next two years?
Natural Disaster choose one Definitely Will Probably Will Probably Will Not Definitely Will Not
Terrorist Attack choose one Definitely Will Probably Will Probably Will Not Definitely Will Not
Public Health Emergency choose one Definitely Will Probably Will Probably Will Not Definitely Will Not
4. If you were instructed by government officials to evacuate to outside the metropolitan area, would you: choose one Have NO place to stay AND NO transportation Have a place to stay AND have transportation Have Transportation, BUT NO place to stay Have a place to stay, BUT NO transportation
5. If you were instructed by government officials to evacuate your home to a shelter that could be reached by walking or public transportation, how LIKELY would you be to do so? choose one Definitely Would Very Likely Somewhat Likely Somewhat Unlikely Very Unlikely Definitely Would Not
5.a. Why would you be UNLIKELY to evacuate? To protect my home Concerned about my possessions Have people in my care Concerned about my pets Concerned about crime/danger Concerned about food/water/supplies in shelter Have alternate place to go Not knowing locations of public emergency shelters Lack of trust in government Personal illness Dislike of crowds Lack of transportation Think my home could withstand event Have special needs that may prevent evacuating
6. Is there a tornado warning siren or some other emergency alert system in your community? choose one Yes No Don’t Know
7. Do you watch Metro 3 Government Access TV? choose one Yes No Didn’t know it existed, but will now
8. What would you suggest as the best way for emergency messages to reach you? TV/news TV/Government Access Channel E-mail Internet Mass telephone calls Radio stations Emergency Alert Weather Radio Highway Message Boards Other
9. Would you and/or a family member take free emergency preparedness classes? choose one Yes No Maybe
9.a. If so, when is the most convenient time? choose one Daytime (8a-4p) Evening (5p-10p)
9.b. When is the most convenient day? choose one Monday-Friday Saturday Sunday
10. How confident are you with your LOCAL government being prepared for major emergencies such as natural disasters or terrorist attacks? choose one Very confident Somewhat confident Not confident Don’t want to answer
11. What would be the best way to get information to you about emergency preparedness, free classes, seminars etc? choose one TV/News TV/Government Access Channel 3 Newspaper Email Radio Internet Other
If Other: If Email, enter valid email address here for OEM emails:
12. Are you or anyone in your household a part of an active Neighborhood Watch Group? choose one Yes No
If no, would you be interested in joining one? choose one Yes No
13. Do you have an Emergency Alert Weather Radio at home? choose one Yes No
14. Here is a short list of things that some people have done to prepare in the event of an emergency situation. What, if any, have you done to prepare? Prepared a disaster supply kit for at home Prepared a small disaster supply kit for the car Prepared a small disaster supply kit for the office Created a communication plan for family Identified meeting locations for family Practiced drills at home Taken a first aid class Taken a CERT class Volunteered for emergency preparations (such as emergency drills etc) Other
15. If you have prepared a disaster supply kit for your home, which of the following do you currently have in your kit at home: 3 day supply of medicines Extra Batteries Flashlight 3 day supply of water 3 day supply of food First Aid Kit Standard AM/FM radio
16. Here are some reasons that people often say for NOT doing things to prepare for an emergency situation like a terrorist act or natural disaster. Thinking about yourself, please indicate if any of the following is a MAJOR reason you haven’t done more. Don’t think an emergency will happen here Don’t know how to prepare Have not thought about it enough Nothing would be effective Cost too much money Takes too much time Don’t want to think about it Don’t have room for an emergency kit
17. Thinking about yourself, please tell us if any of the following is a MAJOR reason you are well prepared: Live in a high risk area Been through emergency before Am responsible for children Am responsible for elderly/disabled I think it is important to be self-sufficient
18. Do you know how to turn off your utilities such as gas, electricity or water? choose one Yes No
19. Are you currently: choose one Employed full time Employed part time Self employed Not employed
19.a. How many people work at your specific office or place of business (best guess): choose one Under 10 10-50 51-100 101-250 251 or more Varies
19.b. Does your employer have a detailed plan for how to respond in different emergency situations? choose one Yes No Don't Know
19.c. Has there been any actual practice or drill of this plan at work in the last 12 months, or not? choose one Yes No Don't Know
19.d. Are you a government employee? choose one Yes - Local govt. Yes - State or Federal govt. No
20. How many children in your household go to daycare or school up through high school? choose one None 1-2 3-4 5 +
21. Including yourself, how many people are currently living in your household? choose one 1 2 3 4 or more Don’t want to answer
22. Do you have anyone staying in your household that has special needs that may need assistance during an emergency situation? choose one Yes No
23. What is your age? choose one 18-24 25-34 35-44 45-54 55-64 65+ Don’t want to answer
24. What is your gender: choose one Male Female Don’t want to answer
25. What is your zip code:
26. What is your Annual Household Income? choose one Less than $15000 $15,000-$24,999 $25,000-$34,999 $35,000-$49,999 $50000-$74,999 $75,000-$99,999 $100,000 or more Don’t want to answer
27. What is the highest grade of school or year of college that you have completed? choose one None Less than high school High school/GED Some college/Vocational College Graduate Don’t want to answer
28. What is your race? choose one African-American/Black American Indian/Alaskan Native Asian Caucasian/White Hispanic/Latino Inter-racial Pacific Islander Other Don’t want to answer