Household Survey for General Public and Consent

OMB Control No: 0920-xxxx

Expiration Date: xx/xx/20xx

Attachment D: Household Survey for General Public and Consent

Public reporting burden of this collection of information is estimated to average 25 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 Information Collection Review Office; 1600 Clifton Road NE, MS D-74, Atlanta, Georgia 30333; ATTN:  PRA (0920-xxxx)

[If the participant is deemed eligible based on the questions from Attachment I: Household Survey for General Public_ Study Screener, please proceed with the following consent and survey]

Before we continue, I'd like you to know that this survey is authorized by the U.S. Public Health Service Act. You may choose not to answer any question you don't want to answer or stop at any time.  Any information you give me will be kept private.  Your responses will be combined with others from your community and will not be linked back to you. This call may be monitored and recorded for quality control. I'd like to continue now unless you have any questions. [INTERVIEWER: IF NEEDED: The interview takes an average 25 minutes to complete depending on your answers.]

I'd like to continue now unless you have any questions.

1 Person Interested, continue.[go to question 1]

Access to Health Services

1. Do you have any kind of health care coverage, including health insurance, prepaid plans such as HMOs, or government plans such as Medicare or Indian Health Services?

Yes

No

Don’t Know / Not sure

Refused

2. Does your health care plan include mental health coverage?

Yes

No

Don’t Know / Not sure

Refused

3. Do you have one person you think of as your personal doctor or health care provider?

If “No,” ask: “Is there more than one, or is there no person who you think of as your personal doctor or health care provider?”

Yes, only one

More than one

No

Don’t Know / Not sure

Refused

4. Was there a time in the past 12 months when you needed to see a doctor but could not because of cost?

Yes

No

Don’t Know / Not sure

Refused

Life Satisfaction and Emotional Support

1. In general, how satisfied are you with your life?

Very satisfied

Satisfied

Dissatisfied

Very dissatisfied

Don’t know

Refused

2. How often do you get the social and emotional support that you need?

Always

Usually

Sometimes

Rarely

Never

Don’t know

Refused

3. How often do you get the health and medical care that you need?

Always

Usually

Sometimes

Rarely

Never

Don’t know

Refused

Life Orientation Test-Revised

Please answer the following questions about yourself by indicating the extent of your agreement using the following scale:

Strongly disagree

Disagree

Neutral

Agree

Strongly agree

1. In uncertain times, I usually expect the best.

2. I’m always optimistic about my future.

3. I hardly ever expect things to go my way.

4. I rarely count on good things happening to me.

Social Connectedness

Response options for the following questions:

Strongly Agree

Agree

Neutral

Disagree

Strongly Disagree

1. I am happy with the friendships I have.

2. I have people with whom I can do enjoyable things.

3. I feel I belong in my community.

4. In a crisis, I would have the support I need from family or friends.

Neighborhood Disorder Scale

Next I would like to ask you some questions about your neighborhood. Please tell me how much you agree or disagree with the following.

Strongly Agree

Agree

Disagree

Strongly Disagree

Don’t know/refuse

1. My neighborhood is safe.

2. My neighborhood is clean.

3. I can trust most people in my neighborhood.

Collective Efficacy Scale

Very likely

Likely

Neither likely nor unlikely (don’t read middle response, don’t know coded here)

Unlikely

Very unlikely

1. If a group of children were skipping school and hanging out on a street corner, how likely is it that your neighbors would do something about it?

2. If some children were spray-painting graffiti on a local building, how likely is it that your neighbors would do something about it?

3. If there was a fight in from of your house and someone was being beaten or threatened, how likely is it your neighbors would break it up?

4. If a child was showing disrespect to an adult, how likely is it that people in your neighborhood would scold that child?

5. Suppose that because of budget cuts the fire station closest to your home was going to be closed down by the city. How likely is it that neighborhood residents would organize to try to do something to keep the fire station open?

For each of these statements, please tell me whether you

Strongly Agree

Agree

Neither agree nor disagree (don’t read middle response, don’t know coded here)

Disagree

Strongly Disagree

6. People around here are willing to help their neighbors.

7. This is a close-knit neighborhood.

8. People in this neighborhood generally don’t get along with each other.

9. People in this neighborhood do not share the same values.

Economic Stability

Now I’m going to ask some questions about your household.

1. What is your estimated annual household income from all sources? Was it....

0-<$15,000

$15,000-<$20,000

$20,000-<$25,000

$25,000-<$35,000

$35,000-<$50,000

$50,000-<$75,000

>$75,000

Unknown/refused

2. What best describes your situation?

I have insurance to cover most of my losses from natural disasters or other catastrophic events

I have insurance to cover some of my losses from natural disasters or other catastrophic events

I have no insurance

Don’t Know

Refused

3. Do you own or rent your home?

Own

Rent

Other arrangement

Don’t Know / Not sure

Refused

[Only ask if answer to previous question is own or rent]

4. How often in the past 12 months would you say you were worried or stressed about having enough money to pay your rent/mortgage? Would you say you were worried or stressed—

Always

Usually

Sometimes

Rarely

Never

Don’t know

Refused

5. How often in the past 12 months would you say you were worried or stressed about having enough money to buy nutritious meals? Would you say you were worried or stressed---

Always

Usually

Sometimes

Rarely

Never

Don’t know

Refused

Quality of Life

Response options for the following questions:

_ _Number of days

None

Don’t Know / Not sure

Refused

1. Now thinking about your physical health, which includes physical illness and injury, for how many days during the past 30 days was your physical health not good?

2. Now thinking about your mental health, which includes stress, depression, and problems with emotions, for how many days during the past 30 days was your mental health not good?

Health Behaviors

1. During the past 30 days, other than your regular job, did you participate in any physical activities or exercises such as running, calisthenics, golf, gardening, or walking for exercise?

Yes

No

Don’t know

Refused

2. During the past 30 days, how many days per week or per month did you have at least one drink of any alcoholic beverage?

__ days per week

__ days per month

Don’t know

No drink in past 30 days

Refused

3. Considering all types of alcoholic beverages, how many times during the past 30 days did you have 5 or more drinks for men or 4 or more drinks for women on an occasion?

__ number of times

None

Don’t know

Refused

4. One drink is equivalent to a 12-ounce beer, a 5-ounce glass of wine, or a drink with one shot of liquor. During the past 30 days, on the days when you drank, about how many drinks did you drink on the average? [A 40 ounce beer would count as 3 drinks, or a cocktail drink with 2 shots would count as 2 drinks.]

__ number of times

None

Don’t know

Refused

5. Have you smoked at least 100 cigarettes in your entire life? [Note: 5 packs = 100 cigarettes]

Yes

No

Don’t know

Refused

6. Do you now smoke cigarettes every day, some days, or not at all?

Every day

Some days

Not at all

Don’t know

Refused

7. In the past 30 days, have you increased your level of prescription or non-prescription medication use without the advice of a doctor or other health care professional?

Yes

No

Don’t know

Refused

Anxiety and Depression

Now, I am going to ask you some questions about your mood. When answering these questions, please think about how many days each of the following has occurred in the past 2 weeks.

Response options for the following questions:

_ _ 01–14 days

None

Don’t Know / Not sure

Refused

1. Over the last 2 weeks, how many days have you had little interest or pleasure in doing things?

2. Over the last 2 weeks, how many days have you felt down, depressed or hopeless?

3. Over the last 2 weeks, how many days have you had trouble falling asleep or staying asleep or sleeping too much?

4. Over the last 2 weeks, how many days have you felt tired or had little energy?

5. Over the last 2 weeks, how many days have you had a poor appetite or eaten too much?

6. Over the last 2 weeks, how many days have you felt bad about yourself or that you were a failure or had let yourself or your family down?

7. Over the last 2 weeks, how many days have you had trouble concentrating on things, such as reading the newspaper or watching the TV?

8. Over the last 2 weeks, how many days have you moved or spoken so slowly that other people could have noticed? Or the opposite – being so fidgety or restless that you were moving around a lot more than usual?

9. Has a doctor or other healthcare provider EVER told you that you have an anxiety disorder (including acute stress disorder, anxiety, generalized anxiety disorder, obsessive-compulsive disorder, panic disorder, phobia, posttraumatic stress disorder, or social anxiety disorder)?

Yes

No

Don’t Know / Not sure

Refused

10. Has a doctor or other healthcare provider EVER told you that you have a depressive disorder (including depression, major depression, dysthymia, or minor depression)?

Yes

No

Don’t Know / Not sure

Refused

11. Are you now taking medicine or receiving treatment from a doctor or other health professional for any type of mental health condition or emotional problem?

Yes

No

Don’t Know / Not sure

Refused

Mental Health Treatment

1. Have you EVER received any sort of counseling for problems with your emotions, nerves, or mental health? [INTERVIEWER PLEASE READ: Please include counseling from a family doctor, psychiatrist, psychologist, social worker, therapist, or clergy.]

Yes

No

Don’t know / not sure

Refused

2. In the past year, how many times have you received counseling for problems with emotions, nerves, or mental health?

__number

Hasn’t received counseling within the past year

Don’t know / not sure

Refused

3. Were you EVER prescribed medication for problems with your emotions, nerves, or

mental health?

Yes

No

Don’t know / not sure

Refused

4. When were you first prescribed medication for problems with your emotions, nerves, or

mental health?

Within the past month- that is, anytime less than 1 month ago.

Within the past year- that is, 1 month but less than 12 months ago.

Within the past 2 years- that is, 1 year but less than 2 years ago.

Two or more years ago.

Don’t Know/ not sure

Refused

Generalized Anxiety Disorder (from GAD-7)

Response options for the following questions:

__ 01-14 days

None

Don’t Know/not sure

Refused

1. Over the last 2 weeks, how many days have you been nervous, anxious, or on edge?

2. Over the last 2 weeks, how many days have you not been able to stop or control worrying?

3. Over the last 2 weeks, how many days have you worried too much about different things?

4. Over the last 2 weeks, how many days have you had trouble relaxing?

5. Over the last 2 weeks, how many days have you been so restless that it was hard to sit still?

6. Over the last 2 weeks, how many days have you been easily annoyed or irritable?

7. Over the last 2 weeks, how many days have you felt afraid as if something awful might happen?

Children’s Mental Health

1. How many children less than 18 years of age live in your household?

Response options for the following questions:

Yes

No

Don’t Know/not sure

Refused

2. Intro During the past 30 days, have any of the children in your household experienced any of the following difficulties:

Been very sad or depressed?

Felt nervous or afraid?

Problems sleeping?

Problems getting along with other children?

Tornado Exposure

Now we’re going to ask some questions about the large tornado outbreak in the Southeast, during April 25-27, 2011.

• Did you live in {X County} during the time of the tornados in April 2011?

• If no, did you live in an area impacted by tornados?

If no to both, skip the whole tornado section.

Approximately how far away (in miles) from the closest tornado were you sheltered during the severe storms? ______

Approximately how far away (in miles) from your home was the closest tornado?_____

1. From April 25-27, during the tornado outbreak while your area was under tornado watch where were you?

At the place where I stayed or lived most of the time

At the home of a relative, in the area where I lived

At the home of a friend, in the area where I lived

At a designated shelter in the area where I lived

At another place

2. Did you feel safe where you were during the tornado watch and warnings?

Yes

No

Not sure

Not applicable

Response options for the following questions:

Yes

No

3. At any point during the time you were under tornado watch and warnings did you leave the place where you were?

4. Did you feel direct threat to life of self or family member?

5. Did you experience death of an immediate family member?

6. Did you experience death of a friend or peer?

7. Did you experience death of a pet?

8. Did you experience any tornado related illness or physical injury of yourself or a family member?

9. Were you trapped by any tornados?

10. Was your home not livable due to any tornados?

11. Did you personally see any tornados?

12. Did you require immediate rescue or emergency services following a tornado?

13. Did you receive medical treatment for any illness or injury that occurred as a result of a tornado?

Screening for DSM-IV PTSD

Response options for the following questions:

Yes

No

1. Do you avoid being reminded of the tornado outbreak by staying away from certain places, people or activities?

2. Have you lost interest in activities that were once important or enjoyable?

3. Have you begun to feel more distant or isolated from other people?

4. Do you find it hard to feel love or affection for other people?

5. Have you begun to feel that there is no point in planning for the future?

6. Have you had more trouble than usual falling or staying asleep?

7. Do you become jumpy or easily startled by ordinary noise or movements?

Community Involvement and Assistance

1. Were you involved with any of the following before the tornados? (check all that apply)

• School (for yourself or your children)

• Church

• Civic organizations (e.g. Boy or Girl Scouts, Rotary club, hobby clubs, VFW, volunteer groups, etc.)

2. Did you become involved with any of the following after the tornados? (check all that apply)

• School (for yourself or your children)

• Church

• Civic organizations (e.g. Boy or Girl Scouts, Rotary club, hobby clubs, VFW, volunteer groups, etc.)

For each of the following, indicate (using the scale) the extent that the place/structure was damaged or destroyed as a result of the tornados.

Not affected at all

Minor damage or closed very briefly

Moderate damage or closed for a short period

Significant damage or closed for an extended period

Destroyed

Not applicable

Don’t know

3. Your home

4. The home of any close friends or family members

5. Your workplace

6. Your school or your child’s school

7. Your church or place of worship

8. Your regular places of recreation (shopping, parks, golf course, etc.)

9. Your or your child’s doctor

10. Civic organizations (e.g. local non-profits, Boy or Girl Scouts, Rotary club, hobby clubs, VFW, volunteer groups, etc.)

11. Other

12. Did you receive any assistance in cleaning up or recovering from the tornado?

Yes

No

13. If yes, who was the assistance from? (check all that apply)

Family and/or Friends

Neighbors

Co-workers

Strangers or new acquaintances

The government

FEMA

HUD

National Guard or Coast Guard

State agencies such as emergency management or state patrol

Social services agency

Local police or fire department

Other local government

Other

Church or place of worship

Red Cross

Other (please specify:______________________________)

Don’t know who provided assistance

14. Did you assist anyone else with cleaning up or recovering from the tornados?

Yes

No

15. If yes, was this work done with a group such as your church or volunteer organization?

Yes (please specify the group or organization:___________________________)

No

16. Besides yourself and your immediate household, who do you feel you can rely on for assistance following a disaster?

Family and/or Friends

Neighbors

Co-workers

Strangers or new acquaintances

The government

FEMA

HUD

National Guard or Coast Guard

State agencies such as emergency management or state patrol

Social services agency

Local police or fire department

Other local government

Other

Church or place of worship

Red Cross

Other

I cannot rely on anyone following a disaster

Exposure to communication about the disaster and available resources

1. Where did you get reliable information about emergency aid in the period immediately following the tornados?

Television

Radio

Internet

Automated call (e.g. reverse 911)

Text messages or smart phone alerts

Local newspaper

Church or other community group

Family, friend, neighbor/word of mouth

Flyer/Poster

Other

No agency, organization or person provided reliable information

2. What has been your most reliable source of information about assistance in trying to recover and rebuild following the tornados?

Television

Radio

Internet

Automated Call (e.g. reverse 911)

Text messages or smart phone alerts

Local newspaper

Church or other community group

Family, friend, neighbor/word of mouth

Flyer/Poster

Other

No agency, organization or person provided reliable information

3. Were you aware that the following service was available in your area?

{The Disaster Recovery Center at Highway 23 and Highway 25 in Monroe County}*

No/Yes

{Service2}

No/Yes

{Service 3}

No/Yes

(etc)

*List of available services gleaned from Interviews with the Public Health and Mental Health Departments in each region; One example included above.

Employment Status

1. How did the tornado outbreak affect your household income?

Decreased

Increased

No Change

Don’t know

Refused

2. Including yourself, how many people in your household lost their jobs due to the tornado outbreak?

___Record number of people

None

Don’t know/not sure

Refused

Perceived Recovery

1. In thinking about your family or other household members before and after the tornados, would you say your household is:

Better off than before the tornados

Recovered: Back to where it was before the tornados

Recovering, Still slightly damaged from the tornados

Recovering, Still damaged from the tornados

Still very heavily damaged from the tornados

Experienced no change since before the tornados

2. In thinking about your community before and after the tornados, would you say your community is:

Fully Recovered, Better off than before the tornados

Recovered, Back to where it was before the tornados

Recovering, Still slightly damaged from the tornados

Recovering, Still damaged from the tornados

Still very heavily damaged from the tornados

Experienced no change since before the tornados

3. On a scale of 1-10 how well has your household recovered from the tornados?

4. On a scale of 1-10 how well has your community recovered from the tornados?

5. Would you say your quality of life is (better) now than it was before the tornados, (worse) now, or is it about the same?

Better

Worse

About the same

Don’t know

Refused

If response to previous question was “worse”:

6. Is that mostly because of the (after effects of the tornados), mostly because of the (country’s recent economic problems), or mostly for other reasons?

Mostly because of the after effects of the tornados

Mostly because of the country’s recent economic problems

Mostly for other reasons

Don’t know

7. Which of the following best describes your personal situation in terms of recovering from the tornados? Would you say that your day to day life is largely back to normal, almost back to normal, still somewhat disrupted, or still very disrupted?

Fully back to normal

Largely back to normal

Almost back to normal

Still somewhat disrupted

Still very disrupted

Don’t know

Refused

8. Overall, would you say [your community] has mostly recovered from the tornados or not?

Yes, has mostly recovered

No, has not

Don’t know

Refused

9. As a place to live, would you say [your community] is (better) now than it was before the tornados, (worse) now than before the tornados, or back to being about the same as it was before the tornados?

Better

Worse

The same

Don’t know

Refused

Demographics

1. I’m sorry but I have to ask. What is your gender?

Male

Female

2. What is your age?

_ _ Age in years

Don‘t know / Not sure

Refused

3. In which of these age categories do you belong?

18-24

25-34

35-44

45-54

55-64

65-74

75-84

85 or older

Don’t Know

Refused

4. Are you Hispanic or Latino?

Yes

No

Don‘t know / Not sure

Refused

5. Which one of these groups would you say represents your race? (Select all that apply)

[READ LIST]

American Indian or Alaska Native

Asian

Black or African American

Native Hawaiian or Other Pacific Islander

White

[DO NOT READ]

Respondent provides category of race not listed above

Don‘t know / Not sure

Refused

6. What is your employment status?

Employed for wages

Self-employed

Out of work for more than 1 year

Out of work for less than 1 year

A homemaker

A student

Retired

Unable to work

Don’t Know

Refused

7. What is your current marital status? Married

Divorced

Widowed

Separated

Never married

A member of an unmarried couple

Don‘t know

Refused

8. How many adults live in your household?