Corps of Engineers Civil Works Questionnaires Generic Clearance

ISLAND HURRICANE EVACUATION SURVEY

(Personal Interview or Mail Survey)

OMB 0710-0001

Expires: 30 September 2012

The public report burden for this information collection is estimated to average 20 minutes per response, including the time for reviewing instructions, searching existing data sources, gathering and maintaining data needed, and completing and reviewing the collection of information. Send comments regarding this burden estimate or any other aspect of this data collection, including suggestions for reducing this burden, to Department of Defense, Washington Headquarters Services, Executive Services Directorate, Information Management Division, and the Office of Information and Regulatory Affairs, Office of Management and Budget, Washington, D.C. 20503: Attn.: Desk Officer for U.S. Army Corps of Engineers. Respondents should be aware that notwithstanding any other provision of law, 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. Please DO NOT RETURN your completed form to either of these offices.

Island Hurricane Evacuation Survey

OMB Control Number 0710-0001

Expiration Date September 30, 2012

Interviewer ID: _______________

Name of Interviewer: ______________________________________________

Questionnaire ID):

__________________________

Describe the residence (Wood or cement; one floor or multiple floors; an individual house or apartments; color of the house, etc.). What type of roof does the structure have (cement, zinc or aluminum, etc.)?

______________________________________________________________________

______________________________________________________________________

______________________________________________________________________

______________________________________________________________________

______________________________________________________________________

______________________________________________________________________

______________________________________________________________________

______________________________________________________________________

______________________________________________________________________

Is the residence located in a valley, or on a hill, near the ocean or next to any other body of water? Describe and identify the distance between the home and the body of water, etc. ______________________________________________________________________

______________________________________________________________________

______________________________________________________________________

______________________________________________________________________

______________________________________________________________________

______________________________________________________________________

______________________________________________________________________

______________________________________________________________________

Date of interview: _____Day ______Month ______Year

Time the interviewer started: _____ Hour _____Minutes

INTRODUCTION

Hello, my name is ________________________. Researchers from the ___________________ are conducting a study regarding the impact of hurricanes and floods in __________________, and the evacuation process in disaster events. This study is funded by the United States Army Corps of Engineers.

We would like to interview the head of the household. (If this person is not present we can interview any other person that is 18 years or older that lives in this residence).

This is a short interview; we estimate that it will last about 20 to 30 minutes. Participation is strictly voluntary, however your responses are very important to us since this information will help us to better prepare our population for disaster situations, and will allow government agencies to provide the necessary assistance in times of crisis.

Before we begin, please allow me to assure you that the information that you provide is confidential and will only be utilized to prepare statistical reports.

For the purpose of our study, we would like to obtain information that will allow us to communicate with you in the future in case we should have any other questions regarding to your responses. We would like to assure you that this information will not be shared or distributed; it will be maintained for purposes specifically related to this study.

NOTE TO THE INTERVIEWER: Reiterate that this information will not be shared or distributed, and will be maintained specifically for research related to this study.

QUESTIONS RELATED TO THE RESIDENCE AND THE COMMUNITTY

1. Do you live in this residence all year round?

1 Yes Go to Q3

5 No Go to Q2

2. Do you reside here at least during half of the hurricane season, from June 1^st to November 30^th?

1 Yes Go to Q3

5 No End the interview

90 Doesn’t know End the interview

91 Refuse End the interview

NOTE TO THE INTERVIEWER: If the answer is “No” end the interview by saying “Thank you for your time, but we are looking for people that are in this region during that time frame. Once again, thank you. Goodbye.”

3. How long have you and your family been living in this residence/apartment?

___________ Months __________ Years

4. How long have you and your family been living in this community?

___________ Months __________ Years

HOUSEHOLD RESIDENTS

5. How many people live with you in your residence, including yourself?

__________

6. Could you indicate who these people are and their relationship to the head of the household?

NOTE TO THE INTERVIEWER: We don’t need the names of the people, we just need the information that appears below.

Sex/Gender of person Age Relationship to the head of the

household (Husband/Wife, Children,)

_________________ _____ __________________________

_________________ _____ __________________________

_________________ _____ __________________________

_________________ _____ __________________________

_________________ _____ __________________________

_________________ _____ __________________________

_________________ _____ __________________________

_________________ _____ __________________________

LOCATION OF THE RESIDENCE IN AT RISK AREAS

7. Can you indicate if this residence is located in an area where it could be affected by the following hazards?

	Yes	No	Doesn’t know	Refuse
7a. Floods by rain	1	5	90	91
7b. Floods by overflow of a river or lake	1	5	90	91
7c. Floods by storm surge or wave action	1	5	90	91
7d. Hurricanes	1	5	90	91
7e. Strong Winds	1	5	90	91
7f. Landslides	1	5	90	91
7g. Flood by tsunami	1	5	90	91
7h. Earthquakes	1	5	90	91

8. Could you indicate if your residence is located near a body of water; for example, the sea, a river, or a lake?

	Yes	No	Does not know	Refused
8a. Ocean/Sea	1	5	90	91
8b. River	1	5	90	91
8c. Lake	1	5	90	91
8d. Other (8d1. Please Specify: ______________)	1	5	90	91

9. Approximately, how far is your house from the closest body of water? (PROVIDE THE DISTANCE CARD TO THE INTERVIEWEE)

_1_ Less than a block

_2_ More than a block but less then a quarter of a mile

_3_ More than a quarter of a mile but less than 1 mile

_4_ More than 1 mile

_90_ Does not know

_91_ Refused

TYPE OF RESIDENCE/HOUSE

10. Which of the following best describes the structure of this house? (PROVIDE THE HOUSE STRUCTURE CARD TO THE INTERVIEWEE)

_1__ Mostly wood

_2__ Mostly cement

_3__ Mostly wood and cement

_4__ Multifamily building

_5__ Another type of structure_______________________________________

_90_ Does not know

_91_ Refused

11. Is your house elevated on stilts?

1 Yes

5 No

90 Does not know

91 Refused

“DISASTER” EXPERIENCES IN YOUR CURRENT RESIDENCE

12. Since you began living in this residence, have any of the following natural hazards occurred that have affected you, your residence or the people that live with you?

Event	Yes	No	Does not know	Refused	Date (month/yr)
12a. Flood by rain?	1	5	90	91	13a1.
12b. Flood by overflow of rivers, lakes, or other body of water?	1	5	90	91	13b1.
12c. Flooding from storm surge or wave action?	1	5	90	91	13c.1
12d. Hurricanes?	1	5	90	91	13d1.
12e. Strong Winds?	1	5	90	91	13e1.
12f. Landslides?	1	5	90	91	13f1.

13. For the abovementioned events that impacted you or your family in your current residence, can you briefly describe the event, how you were affected, if there were any financial loses or if you had to evacuate the residence?

NOTE TO THE INTERVIEWER: The interviewer must assure that the previous questions are answered, among other issues that may emerge.

_____________________________________________________________________

_____________________________________________________________________

_____________________________________________________________________

_____________________________________________________________________

_____________________________________________________________________

_____________________________________________________________________

_____________________________________________________________________

_____________________________________________________________________

POTENTIAL HAZARD EVENTS

Suppose that there is a very strong hurricane in the ____________ that is coming towards __________, let’s say it is a Category 3 (wind speeds between 111 and 130 mph). It is a dangerous storm and it looks like it could hit this area. The National Hurricane Center has announced a watch for this area. In other words, it is possible that within the next 36 hours you may be exposed to hurricane conditions, but there could be floods in low-lying areas and roads before the worst part of the hurricane arrives. Nevertheless, public officials have not advised to take any specific actions.

14. Do you think that you and the people that live with you would evacuate under such circumstances? (When we say evacuate, we mean go to another place where you believe it will be safe if the hurricane hits, it could be in the surrounding area or far away).

_____ Yes, most likely we would evacuate (Go to Question 15)

_____ No, most likely we would not evacuate

14A. Would you please indicate the reasons why you would not evacuate? Please

check all that apply (PROVIDE THE EVACUATION CARD TO THE INTERVIEWEE)

_1__ My house is safe

_2_ I do not have transportation

_3__ I do not have anywhere to go

_4__ I want to protect my property from vandalism and looting

_5__ I want to protect my home from the hurricane

_6__ I left once before and nothing happened

_7__ My job requires me to stay, I need to work

_8__ I don’t want to leave my pets

9__ Other Reason/ Please Specify

_90_ Does not know

_91_ Refused

15. Let’s assume that this storm (Category 3 with wind speeds ranging from 111 and 130 mph) is now much closer. The National Hurricane Center has announced a Warning for this area, which means that hurricane conditions are expected within the next 24 hours, and public officials have ordered citizens to evacuate.

Under these circumstances, do you think that you or the people living with you will evacuate the home?

1 Yes, we would most likely evacuate (Go to question 16)

5 No, most likely we would not evacuate

90 Does not know

91 Refused

15A. Can you please indicate the reasons why you and your family would not evacuate? (Please select all that apply). (PROVIDE THE EVACUATION CARD TO THE INTERVIEWEE)

_ 1__ My house is safe

_2__ I don’t have transportation

_3__ I don’t have any place to go

_4__ I want to protect my property from vandalism and looting

_ 5__ I want to protect my home from the hurricane GO TO Q.18

_6__ I evacuated last time and nothing happened

_7__ My job requires me to stay, I have to work

_ 8__ I don’t want to leave my pets

_ 9__ Other reason (please, specify)

_90_ does not know

_ 91_ Refused

16. You indicated that, under circumstances of extreme danger, you and your family would evacuate. Can you indicate where you will probably go?

_1_ A public shelter

_2_ A church

_3_ A friend’s home

_4_ A family member’s home

_5_ A hotel or motel

_6_ To your job

_7_ Another place (Please specify:_________________________________)

_90 Does not know

91 Refused

17. If you evacuate, would you stay in the same community or would you go to another place?

_1_ I would stay in the same community

_2_ I would go to another community (Specify the community:_____________)

_3_ I would leave Puerto Rico (17a. Please specify______________________)

_90 Does not know

_91 Refused

17A. Once you have heard public officials give an order to evacuate this area, how long do you think it would take your family to be ready to leave this residence.

___ Less than 1 hour

___ 1 to 2 hours

___ 2.01 to 5 hours

___ 5.01 to 10 hours

___ 10.01 to 18 hours

___ 18.01 to 24 hours

___ Greater than 24 hours

18. Is there a location close to your residence that has been designated as a public shelter for residents that would need to evacuate in case of an emergency or a disaster?

_1__ Yes

_

Go to Q. 19

5__ No

_ 90_ Does not know

_91_ Refused

18A. If there is a location that serves as a public shelter, how far away is it from your home? (PROVIDE THE CARD TO THE INTERVIEWEE)

_1_ Less than a block

_2_ More than a block but less then a quarter of a mile

_3_ More than a quarter of a mile but less than 1 mile

_4_ More than 1 mile

_90_ Does not know

_91_ Refused

19. If you had to evacuate, do you have friends or family that you could stay with instead of going to a public shelter?

1 Yes

Go to Q. 20

5 No

90 Does not know

91 Refused

19A. How far away do these family or friends live from your home? (PROVIDE THE DISTANCE CARD TO THE INTERVIEWEE)

_1_ Less than a block

_2_ More than a block but less then a quarter of a mile

_3_ More than a quarter of a mile but less than 1 mile

_4_ More than 1 mile

_90_ Does not know

_91_ Refused

RESIDENTS WITH SPECIAL NEEDS

20. Is there someone in your home that needs special assistance during an emergency or a disaster?

_1__ Yes Go to Q. 20A

_

Go to Q. 21

5__ No

_90_ Does not know

_ 91_ Refused

20A. If there is anyone in your home that would need special assistance, please indicate this or these person’s condition? Please tell me all that may apply. (PROVIDE THE HEALTH CONDITION CARD TO THE INTERVIEWEE)

Condition	Yes	No	DO NOT KNOW	REFUSE
20a1. Blindness?	1	5	90	91
20a2. Deafness?	1	5	90	91
20a3. Is the person unable to walk?	1	5	90	91
20a4. Someone who can only walk with assistance?	1	5	90	91
20a5. Someone with a chronic disease such as cancer, diabetes or Alzheimer’s or any other disease of this type?	1	5	90	91
20a6. Mental conditions?	1	5	90	91
20a7. Other diseases? Which?____________________________________ ____________________________________	1	5	90	91

20B. In an emergency or disaster situation, who is responsible for providing assistance to this person?

_1_ An agency (Which agency?_____________________________________)

_2_ A friend or family member in the home

_3_ A Friend or family member outside the home

_5_ Other (Please specify:_________________________________________)

_90 Does not know

_91 Refused

20C. In a crisis or disaster situation, would this person need special transportation (e.g., ambulance) or another type of special services?

_1_ Only transportation (Ambulance)

2 Special Needs/ 20c1. Please Specify _______________________________

3 Other/ Specify 20c2. Please Specify _______________________________

4 Does not know

5 Refused

20D. Do you think that public shelters have the necessary resources to provide assistance to the resident(s) of your house that have special needs?

_1_ Yes _5_ No 90 Does not know 91 Refused

TRANSPORTATION IN THE RESIDENCE

21. Please indicate how many cars or other motorized vehicles in working order are available to you at your residence?

____ Number of motorized vehicles

0 None

_ 90 Does not Know

91 Refused

22. How many motorized vehicles would you and the members of your family use during an evacuation?

____ Number of motorized vehicles

0 None

_ 90 Does not know

91 Refused

23. In a disaster like a hurricane or a flood, would you or the members of your family need an agency or organization to provide transportation to evacuate your home?

_1_ Yes _5_ No 90 Does not know 91 Refused

24. In a disaster situation like a hurricane or a flood, do you expect to tow a trailer, boat or a motor home or any other equipment?

_1_ Yes _5_ No 90 Does not know 91 Refused

EXPERIENCE AND BEHAVIOR WITH PREVIOUS DISASTERS

25. Could you tell us what was the most recent event or disaster that impacted this community since you have been living here?

Type of Event (select the most recent):

_1_ Flood by rain

_2_ Flood by overflow of river, lake, or gulch

_3_ Flood by surge or wave action

_4_ Hurricanes

_5_ Strong winds

_6_ Landslide

_7_ Other (Specify)__________________________________

_8_ None

_90 DOES NOT KNOW

_91 REFUSED

We would like to ask some questions in relation to the most recent event that you identified in the previous question.

26. Can you tell us the approximate date when this event took place?

Month:________ Year:________

26A. If the event was a hurricane, could you please indicate the name of the hurricane?

Name of hurricane: __________________________________

27. Before the event or disaster, did you hear any public official indicating that you had to evacuate your area or home?

_1_ Yes

_2_ No

_3_ Cannot remember

_90 DOES NOT KNOW

_91 REFUSED

28. What did you do during this event or disaster? (PROVIDE THE DISASTER ACTION CARD TO THE INTERVIEWEE)

1 I stayed in the house

I evacuated to:

2 A public shelter in my community

3 A public shelter outside of my community

4 A hotel/motel in my community

5 A hotel/motel outside of my community

6 A family’s or friend’s house in my community

7 A family’s or friend’s house outside of my community

8 A church in my community

9 A church outside of my community

10 My workplace in my community

11 My workplace outside of my community

12 Another place within _________; please specify:___________

13 I traveled outside of ___________; please specify:___________

90 CANNOT REMEMBER / DOES NOT KNOW

91 REFUSED

29. Did you live in this area and were you in your home in _______ when Hurricane _________ occurred?

1 Yes

Go to Q. 33

5 No

90 CANNOT REMEMBER / DOES NOT KNOW

9 1 REFUSED

30. During Hurricane ___________ in _____ did you hear a warning to evacuate the area?

1 Yes

5 No

90 CANNOT REMEMBER / DOES NOT KNOW

91 REFUSED

31. What did you do during Hurricane ________? (PROVIDE DISASTER ACTION CARD TO INTERVIEWEE)

1 I stayed in the house

I evacuated to:

2 A public shelter in the my community

3 A public shelter outside of my community

4 A hotel/motel in my community

5 A hotel/motel outside of my community

6 A family’s or friend’s house in my community

7 A family’s or friend’s house outside of my community

8 A church in my community

9 A church outside of my community

10 My workplace in my community

11 My workplace outside of my community

12 Another place within _________; please specify:___________

13 I traveled outside of _________; please specify:___________

90 Cannot remember/Does not know

91 RefuseD

32. Was your house flooded during Hurricane ______?

1 Yes

5 No

90 Does not know / cannot remember

91 Refused

BEHAVIORAL PATTERNS DURING A HURRICANE

33. During a weak hurricane, suppose of a category 2 or less, with sustained winds of less than 110 mph, do you think your home would be at risk of flooding due to tides or waves?

1 Yes

5 No

90 Does not know / cannot remember

91 Refused

34. Considering wind as much as water, do you think it would be safe for you and your family to stay in your home during a weak hurricane, meaning one with winds of less than 110 mph?

1 Yes

5 No

90 Does not know / Is not sure

91 Refused

35. During a weak hurricane do you think public officials would call for an evacuation in your neighborhood, sector or community?

1 Yes

5 No

90 DOES NOT KNOW / IS NOT SURE

91 REFUSED

36. In a weak hurricane, would you evacuate at the request of public officials?

1 Yes

5 No

90 DOES NOT KNOW / IS NOT SURE

91 REFUSED

37. In a strong hurricane with winds of over 125 mph, do you think your house would be in danger of floods due to storm surge or high waves?

1 Yes

5 No

90 DOES NOT KNOW / IS NOT SURE

91 REFUSED

38. Considering wind as much as water, do you think it would be safe to stay in your home during a strong hurricane?

1 Yes

5 No

90 DOES NOT KNOW / IS NOT SURE

91 REFUSED

39. In the case of a strong hurricane, if public officials ordered people at risk to evacuate, do you think the order would include you?

1 Yes

5 No

90 DOES NOT KNOW / IS NOT SURE

91 REFUSED

40. In a strong hurricane, would you evacuate at the request of public officials?

1 Yes

5 No

90 DOES NOT KNOW / IS NOT SURE

91 REFUSED

41. Can you please indicate under what circumstances you would definitely evacuate your home? Please be as specific as possible.

______________________________________________________________________

______________________________________________________________________

______________________________________________________________________

______________________________________________________________________

______________________________________________________________________

INFORMATION ABOUT DISASTER SITUATIONS

42. There are many ways to obtain information about threatening natural disasters, which of the following do you utilize? (PROVIDE THE MEDIA CARD TO THE INTERVIEWEE) Please select all that apply.

	Used or not
Source	Yes	No	Does not know	REFUSED
42a. Local Television, such as ______, _______, _______, or __________.	1	5	90	91
42b. Cable or Satellite Television such as CNN, NBC, CBS, FOX, Weather channel, etc.	1	5	90	91
42c. Local Radio	1	5	90	91
42d. Newspaper	1	5	90	91
42e. Internet	1	5	90	91
42f. Friends	1	5	90	91
42g. Relatives	1	5	90	91
42h.Other.. Specify __________________________	1	5	90	91

43. Thinking about those same disaster information sources, using a scale from 1 to 10, where 1 means that you don’t trust in this source and 10 being that you have plenty of trust in this source, how many points would you give each source? Remember you can give any points between 1 and 10. (PROVIDE THE MEDIA CARD TO THE INTERVIEWEE)

	Used or not
Source	Points	Don’t know	REFUSE
43a. How about your local television stations such as ______, _______, _______, or __________., how many points would you give them?		90	91
43b. Cable or Satellite Television (CNN, NBC,CBS, FOX, Weather channel, etc.)		90	91
43c. Local Radio		90	91
43d. Newspaper		90	91
43e. Internet		90	91
43f. Friends		90	91
43g. Relatives		90	91
43h.Other. 43h1. Specify ___________________________		90	91

44. Thinking of different agencies and government officials that provide information when there are disaster situations, using a scale from 1 to 10, where 1 signifies that you do not trust this source and 10 being that you completely trust this source, what score would you give each of the following sources? Remember that you can give each source a score between 1 and 10.

Source	Points	Doesn’t know	REFUSE
44a. What score would you give to the Emergency Management office of this municipality?		90	91
44b. The _________ State Emergency Management Agency?		90	91
44c. The State police?
44d. What about the Fire Department?		90	91
44e. The National Weather Service?		90	91
44f. The mayor of this municipality?
44g. The governor?		90	91

DISASTER PREPAREDNESS

45. Do you have any type of insurance that covers damages to your residence or property resulting from the impact of a disaster (floods, hurricanes, etc.)?

1 Yes

5 No

90 Does not know

91 Refused

46. There is a variety of equipment that can help people deal with or better respond to a disaster situation like a hurricane. I am going to read you a list of these types of equipment. Please indicate which of them you have or are used to having in your home during the hurricane season.

	Yes	No	Does not know	REFUSED
46a. Do you have a power generator	1	5	90	91
46b. Lantern or flashlight?	1	5	90	91
46c. A battery operated radio?	1	5	90	91
46d. A NOAA weather radio?	1	5	90	91
46e. An oil lamp?	1	5	90	91
46f. Candles?	1	5	90	91
46g. A Cistern or water tank?	1	5	90	91
46h First Aid Kit?	1	5	90	91
46i. Any other thing? (Specify:_____________ ________________________________)	1	5	90	91

47. Do you have a family plan for disasters?

1 Yes

5 No

90 Does not know

91 Refused

Finally, for statistical purposes, we would like to collect some demographic information. Remember that all of these answers will remain strictly confidential.

48. In what year were you born? (WRITE DOWN THE YEAR)

__________

99 REFUSED

49. Do you have any pets in your home?

1 Yes

5 No

90 Does not know

91 Refused

50. What is the highest level of education that you completed? (PROVIDE THE EDUCATION CARD TO THE INTERVIEWEE)

1 Less than High School

2 Various years of High School

3 I graduated from High School

4 Some years of College/ University

5 Completed a Bachelors Degree

6 Completed a Masters degree

7 Completed a Doctorate

8 Completed a professional degree (MD/Doctor, Dentist, Lawyer)

9 Other. Please Specify_____________________________________

90 Does not Know

91 Refused

51. Which of the following options best describes your current situation in reference to a job outside the home? (HAND WORK CARD)

1 I am employed full time (35 hours or more a week)

2 I am employed part time (less than 35 hours a week)

3 I am unemployed

4 I am retired

5 I am a stay at home father/mother/spouse

6 I am a full-time Student

90 Does not know

91 Refused

52. Which of the following categories best describes the total household income for 2007? Please only indicate the letter that corresponds to your household income.

_1_ Less than $5,000 (A)

_2_ $5,000-9,999 (B)

_3_ $10,000-19,999 (C)

_4_ $20,000-29,999 (D)

_5_ $30,000-39,999 (E)

_6_ $40,000-49,999 (F)

_7_ $50,000-59,999 (G)

_8_ $60,000-69,999 (H)

_9_ $70,000 or higher (I)

90 Does not know

91 Refused

53. Are you or your family owners of this house/apartment or are you renting?

1 Owners of this home/apartment (A Mortgage falls into this category)

2 Renting

90 Does not know

91 Refused

54. If you’re the owner of the home/apartment, would you please indicate the approximate value of your home?

$ _________________________

90 Does not Know

91 Refused

We have now concluded the interview. However, there is one more thing I need to ask. Is it possible for my supervisor to contact you to verify that I conducted this interview? Can you please provide your phone number or your email. This information will only be utilized to verify that this interview was conducted and will be saved separately from the other information that you have provided.

Phone Number: ________________________________

Email: ________________________________________

THIS COMPLETES OUR INTERVIEW.

THANK YOU FOR YOUR TIME AND INFORMATION.

Time the interview ended _________ Hour _________ Minutes

Interview Length _________ Minutes

QUESTIONS TO BE ANSWERED THROUGH DIRECT OBSERVATION

Gender of the person being interviewed:

_____ Male

_____ Female

Comments about the interview (Disposition of the person being interviewed, irregularities, problems, etc)

DISTANCE CARD

____ Less than a block

____ More than a block less than a quarter of a mile

____ More than a quarter of a mile but less than a mile

____ More than a mile

HOUSE STRUCTURE CARD

____ Mostly of Wood

____ Mostly of Cement

____ Cement and wood

____ Multi-Family building

____ Other type of structure__________________________________________

EVACUATION CARD

____ My house is safe

____ I do not have transportation

____ I do not have anywhere to go

____ I want to protect my property from vandalism and looting

____ I want to protect my home from the hurricane

____ I left once before and nothing happened

____ My job requires me to stay, I need to work

____ I don’t want to leave my pets

____ Other Reason/Please Specify____________________________________

HEALTH CONDITION CARD

____ Blind

____ Deaf

____ Cannot walk

____ Can walk but will need assistance

____ Has a chronic illness (cancer, diabetes, etc.)

____ Has mental health problems

____ Other type of condition/Please Specify____________________________

DISASTER ACTION CARD

____I stayed in the house

____I evacuated to:

____A public shelter in my community

____A public shelter outside of my community

____A hotel/motel in my community

____A hotel/motel outside of my community

____A family’s or friend’s house in my community

____A family’s or friend’s house outside of my community

____A church in my community

____A church outside out of my community

____My workplace in my community

____My workplace outside of my community

____Another place within _________; please specify:___________

____I traveled outside of _________; please specify:___________

INCOME CARD

___A. Less than $5,000

___B. $5,000-9,999

___C. $10,000-19,999

___D. $20,000-29,999

___E. $30,000-39,999

___F. $40,000-49,999

___G. $50,000-59,999

___H. $60,000-69,999

___I. $70,000 or higher

MEDIA CARD

_____ Local televisión, such as ______, _______, _______, or __________.

_____ Cable Television or Satellite (CNN, NBC, CBS, FOX, etc.)

_____ Local Radio

_____ Newspapers

_____ Internet

_____ Friends

_____ Family Members

_____ Other sources (Specify:_____________________________)

EDUCATION CARD

____ Less than High School

____ Various years of High School

____ I graduated from High School

____ Some years of College/ University

____ Completed a Bachelors Degree

____ Completed a Masters degree

____ Completed a Doctorate

____ Completed a professional degree (MD/Doctor, Dentist, Lawyer)

____ Other. Please Specify_____________________________________

WORK CARD

____ I am employed full time (35 hours or more a week)

____ I am employed part time (less than 35 hours a week)

____ I am unemployed

____ I am retired

____ I am a stay at home father/mother/spouse

____ I am a full-time Student

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