OMB Control No. 0693-XXXX
Expiration Date: XX-XX-2011
Questionnaire on Emergency Procedures
Purpose |
This survey is being conducted by the National Institute of Standards and Technology (NIST), an agency of the U.S. Department of Commerce, in order to improve the emergency procedures of this building.
Completing this questionnaire is voluntary, but your assistance would be greatly appreciated. Your responses will be completely anonymous.
Please return this questionnaire using the provided self-addressed, stamped envelope |
SECTION 1: Background information |
(1) What year did you begin living/working in this particular building? _____________ I am a visitor Don’t know / Refuse
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(2) Have you ever been in an actual building fire before? Never Yes, in this building Yes, in another building
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(3) Have you witnessed any evacuations of this building that turned out to be a false alarm? Never Yes – how many? __________________ (please specify a number)
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(4) Have you received any form of fire drill or emergency training for this building? Never Yes, but not in the past 12 months Yes, in the past 12 months
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(5a) If you have received training in emergency procedures for this building, you received the training through (check all that apply): Fire Department Video Orientation Fire drills Other______________ (please specify) (5b) If drills, how many fire drills have you participated in? __________ (please specify #)
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(6) What fire evacuation procedure were you told to follow? ______________________________________________________________________________________________________________________________________________________________
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(7a) Sex: F M (7b) How old are you? 18-25 26-35 36-45 46-55 56-65 66+ (7c) Current Status: Single Married In a committed relationship (7d) Do you have any children/dependents? Yes No (7e) Education: High school graduate Some college College degree Advanced degree (7f) What is your first language? English Spanish Other _______(please specify)
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(8) Do you require help during an evacuation? Yes No
(9) Do you have any of the following limitations that could impede your evacuation?
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SECTION 2: Prior to leaving your floor |
(10a) Prior to the alarm sounding, what were you doing? ______________________________ (10b) On what floor were you located? ______
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(11) At which location were you when the drill began? To be tailored to rooms in involved building. your own office/room restroom cafeteria stairwell colleague’s office/room elevator basement storage / copy area meeting room corridor first floor lobby other, specify __________
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(12a) Did you hear the fire alarm? Yes No; (12b) If unable, did you see the strobe lights flashing? Yes No (12c) If not, how were you alerted to the drill? _______________
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(13) If you heard the alarm, was the alarm: too loud loud enough too quiet
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(14) If you heard the alarm, please answer the following: (14a) Did you hear the alarm tone? Yes No; (14b) If yes, what did it sound like? ________________________________________________ (14c) Did you receive instructions through the speakers? Yes No (14d) If yes, what were the instructions? ____________________________________________
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(15) When the alarm started to sound, what did you think it was? a fire alarm a car alarm a security alarm other, specify_______________ you didn’t know what the alarm was
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(16) What did you think was going on? a real fire emergency a false alarm a test of equipment don’t know a fire drill a weather emergency a security situation other, describe_______ |
(17) Upon hearing the fire alarm and/or seeing the strobe, please number the following actions from what you did first (1) to what you did next (2), until you entered the stairwell? _____continued prior activity _____waited (for instructions , to see what others were doing , to see if anything else would happen ) _____looked around _____investigated – looked for the source of the alarm (where did you go? ___________) _____sought more information about the alarm _____gathered coat / shoes, dressed (what things? ______________) _____gathered valuables (what things _________________) _____gathered emergency/coordinator supplies (what things? _____________) _____saved file/turned off computer _____secured files/documents _____secured office/room/space (shut door , turn out light(s) , other? ______________) _____followed instructions From whom? _______________________________ _____gave instructions to others on what to do _____discussed with others (inside the building , outside of the building ), about what? _______ _____looked for others in the building _____evacuated the floor _____other ____________________________(please specify) _____other ____________________________(please specify)
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(18) What were others doing around you? ______________________________________________________________________________ ______________________________________________________________________________
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(19a) Did you feel at risk (in danger) at any time? Yes – high level Yes - moderate level No. (19b) Did you feel that others were at risk at any time? Yes – high level Yes - moderate level No.
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(20) What was the one thing that made you decide to evacuate? ______________________________________________________________________________
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(21a) When you first became aware of the drill on your floor, were you: alone with friends/colleagues in the presence of strangers (21b) How many people were with you? _____________________________
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(22) From the time you became aware of the drill until you entered the stair, how many minutes passed? ________min
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(23a) Did you receive information/instructions that influenced your behavior while on your floor? Yes No; (23b) If Yes, where did it come from (mark all that apply): The alarm Staff member Another evacuee A manager Other– Who? _____ (23c) If Yes, what was this information? ________________________________________________________________________ ______________________________________________________________________________ |
SECTION 3: Your evacuation during the drill |
(24a) Was an evacuation coordinator (e.g. fire warden, Resident Assistant, etc.) present on the floor during today’s fire drill? Yes No (24b) Are you an evacuation coordinator? Yes No
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(25) Did you find the evacuation coordinator to be helpful to your evacuation? Yes No
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(26) Did you have difficulty locating a stairwell, elevator, or exit? Yes No
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(27)
What was the primary reason which led you to a particular exit?
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(28a) Did you evacuate? Yes No; If no, please use additional comments to explain why (28b) If yes, how did you evacuate? Stairwell Moved to another floor Went to an area of refuge inside building Elevator Walked directly outside Other
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(29) If you left by a stairwell, did you use… Stair __ Stair __ [Designations, e.g., A, 1, north, blue, to be tailored to involved stairwells.]
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(30)
If you left by a stairwell, how often do you use this stairwell?
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(31a) When you were evacuating via the stair, were you
(31b) How many people were with you? _____________________________
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1 (32) If you left by a stairwell, please check any of the conditions you encountered:
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(33) From the time you entered the stair until you left the building, how many minutes passed? ________min
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(34a) Did you receive information or instructions that influenced your behavior while in stair/elevator? Yes No; (34b) If Yes, where did it come from (mark all that apply): The alarm Staff member Another evacuee A manager Other– Who? ___________ (34c) If Yes, what was this information? ____________________________________________
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(35) If you exited the building, which exit did you use? [Designations, e.g., A, 1, north, blue, to be tailored to involved building.] Exit ___ Exit ___ Exit ___ Exit ___ Exit ___ Exit ___ Other___________________________(please specify)
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(36a) Did you attempt to use an elevator? Yes No (36b) If you used an elevator, what was your primary reason for not using a stairwell? I
have a condition which requires me to use an elevator |
Any Additional Comments:
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Thank
you for taking the time to help us improve
emergency procedures
and safety!
NOTE: This questionnaire contains collection of information requirements subject to the Paperwork Reduction Act (PRA). Notwithstanding any other provisions of the law, no person is required to respond to, nor shall any person be subject to penalty for failure to comply with, a collection of information subject to the requirements of the PRA. The estimated response time for this questionnaire is 10 minutes. The response time includes the time for reviewing instructions, searching existing data sources, gathering and maintaining the data needed, and completing and reviewing the collection of information. Send comments regarding this estimate or any other aspects of this collection of information, including suggestions for reducing the length of this questionnaire, to the National Institute of Standards and Technology, Attn., Erica Kuligowski, erica.kuligowski@nist.gov, 301-975-2309.
File Type | application/msword |
File Title | Questionnaire on Emergency Procedures |
Author | bfaverty |
File Modified | 2008-08-01 |
File Created | 2008-08-01 |