Sample - Household survey

Appendix F Household Survey Sample

Form Approved

OMB No. 0923-0051

Exp. Date 02/28/2024

Interviewer__________ Household ID___________

Date _____________ Start time _____________ End time ______________

Cluster/Zone __________ Latitude _______________ Longitude ______________

Type of residence

Single family Multiple unit Mobile home Other ________________________

HOUSEHOLD SURVEY

Module: Contact Information

1. What is your full name? __________________________________________________

2. What is your street address?

Street Apt

City __ State __ __ Zip Code:

3. What is the best telephone number to reach you in case we have questions about your survey? Please specify if this is a cellular phone, house phone, or work phone.

( __ __ __ ) __ __ __ ‑ __ __ __ __ Cell House Work

Module: Demographics

1. How many people live in this residence? _____

How many are male? _____ How many are female? ­­­­­_____

2. How many people that live here are less than two years old? _____

217 years old? _____ 1864 years old? _____ More than 64 years old? _____

3. How many people in this household are of Hispanic, Latino, or Spanish origin? ­­­­_____

4. To which race do members of this household most identify? I will read a list of races. Please tell me how many people in the household identify as being that race. Record the number of people of each race described:

_____ Black _____ American Indian/Alaska Native

_____ White _____ Native Hawaiian or other Pacific Islander

_____ Asian

Public reporting burden of this collection of information is estimated to average 10 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 Reports Clearance Officer; 1600 Clifton Road NE, MS E-11 Atlanta, Georgia 30333; ATTN: PRA (0923-0051)

Module: Location/Exposure and Communications

1. Was anyone home at any time between [Incident Date/Time] and [End Date/Time]?

Yes

No

2. After [the incident] did you or anyone else in your household detect any unusual smells or tastes that you think were related to the incident?

Yes

No

Did you or anyone else in your household shelter in place, meaning staying inside, with doors and windows closed and all ventilation systems turned off? If yes, ask the respondent: Where did you shelter in place? At home At work At school In your vehicle Other(Please specify):	Yes No Unsure
Did you follow instructions about shelter in place?	Yes No Unsure
Did you or anyone else in your household smell an odor? If no or unsure skip questions I and j.	Yes No Unsure
Can you please describe the odor? Gasoline Rotten eggs Chemical Smell Paint or paint thinner Bug spray Smoke Sewage Other(Please specify):
Would you describe the odor as light, moderate or severe?	Light Moderate Severe
Did you or anyone else in your household come in contact with? Smoke cloud Dust Debris Fog Other(Please specify): Unsure

9. How did your family first receive information or instructions about the incident? Check only one.

Noticed odor/saw chemical Directly from person in authority (police, firefighter)

Reverse 911 call to landline phone Reverse 911 call to cell phone

Call to landline phone Call to cell phone

TV Radio

Text message on a cell phone Social media (Facebook, Twitter)

Directly from another person (such as friend or relative)

Other (Please specify):______________________________________________________

10. As the incident progressed, how did you obtain information? Check all that apply.

Directly from person in authority (police, firefighter)

Reverse 911 call to landline phone Reverse 911 call to cell phone

Call to landline phone Call to cell phone

TV Radio

Text message on a cell phone Social media

Website Community meeting

Newspaper

Directly from another person (such as friend or relative)

Other (Please specify):______________________________________________________

11. Did your household evacuate after [the incident]?

Yes

No Go to Question D1

12. Which day and at approximately what time did you evacuate?

____/____/______ ____:_____ AM PM

MM DD YYYY

Module: Health Status

1. I’m going to ask you some questions about symptoms that could be related to the [Incident]. The appropriate symptoms for the incident should be selected ahead of time. Fill out the table provided below for each one.

	Did anyone in your household experience [Symptom] since the incident? If yes, go to ii. If no, repeat i for next symptom.		If anyone in your household experienced this [Symptom] before the incident did it get worse?		Is anyone in your household still experiencing [Symptom]? Repeat i for next symptom.
	Yes	No	Yes	No	Yes	No
GENERAL
Fever
Chills
Generalized weakness
Body pain
Severe bleeding
EYES
Increased tearing
Irritation/pain/ burning of eyes
Blurred vision/double vision
Bleeding in eyes
EAR/NOSE/THROAT
Runny nose
Burning nose or throat
Nose Bleeds
Hoarseness
Increased salivation
Ringing in ears
Difficulty swallowing
Swollen neck
Pain in jaw
Odor on breath (Gasoline or other, specify)
Stuffy nose/sinus congestion
Increased congestion or phlegm
NERVOUS SYSTEM
Headache
Dizziness or lightheadedness
Loss of consciousness/fainting
Seizures or convulsions
Numbness, pins and needles, or funny feeling in arms or legs
Confusion
Difficulty concentrating
Difficulty remembering things
Concussion
Loss of balance
MUSCLE/JOINT/BONES
Weakness of arms
Weakness of legs
Joint swelling
Muscle weakness
Muscle twitching
Tremors in arms or legs
Joint pain
Broken bone/fracture
Dislocation
Sprain or strain
Whiplash
HEART AND LUNGS
Breathing slow
Breathing fast
Difficulty breathing/feeling out-of-breath
Coughing
Wheezing in chest
Slow heart rate/pulse
Fast heart rate/pulse
Chest tightness or pain/angina
Bronchitis
Pneumonia
Burning lungs
STOMACH/INTESTINES
Nausea
Non-bloody vomiting
Non-bloody diarrhea
Bloody vomiting
Blood in stool/diarrhea
Abdominal pain
Fecal incontinence or inability to control bowel movements
Bowel perforation
SKIN
Irritation, pain, or burning of skin
Skin rash
Hives
Skin blisters
Bumps containing pus
Nail changes
Hair loss in area of rash
Hair loss
Dry or itchy skin
Sweating
Cool or pale skin
Skin discoloration
Poor wound healing
Petechiae/Pinpoint round spots
Blue coloring of ends of fingers/toes or lips
Lips turning blue
Abrasion/scrape
Bruise
Cut
KIDNEY/BLADDER
Urinary incontinence or dribbling pee
Inability to urinate or pee
Blood in urine
Painful urine
PSYCHIATRIC
Anxiety
Agitation/irritability
Thoughts of suicide
Fatigue/tiredness
Difficulty sleeping
Difficulty staying asleep
Feeling depressed
Hallucinations
Paranoia
Unexplained fear
Tension or nervousness
Any other symptoms? If yes, What was it? Record below.
1.
2.
3.
4.

Module : Medical Care Received

1.Did you or anyone in your family receive medical care or a medical evaluation because of the incident?

Yes  Go to Question 3

No

2. Why didn’t you seek medical care?

Did not have symptoms    

Symptoms were not bad enough    

Don’t like to go to the doctor

Didn’t want to take time

Worried about who would pay for the medical visit

Worried about losing job

Other (Please specify): ______________________________________________

Unsure

For those individuals who did not seek medical care, go to the next module.

3. Please tell me if any of the following describe why you sought medical care. Read questions a-c to the respondent and circle the appropriate answer(s).

1. You were given instructions to seek medical care? Yes No Unsure

2. You experienced health problems or symptoms
   within 24 hours of the incident? Yes No Unsure

3. You were worried about possible health
   problems associated with the incident? Yes No Unsure

4. For each person who received medical care, please tell me the person’s name, where they received care, and the date. Please include medical evaluations by emergency medical services or EMTs, hospitals, and doctor’s offices.

Name	Where Received Care	Date

5. If a hospital was named, ask: Was [name] treated and released from the emergency department or hospitalized? If hospitalized, ask: How long was [he/she] hospitalized?

Name	Treated and Released	Hospitalized	Duration of Hospitalization

Module: Needs

1. As a result of the incident, does your household need any of the following…

Read all choices to the respondent.

(check all that apply)

 Medicine or medical supplies

 Medical care

 Mental health care

 Water

 Shelter

 Food

 Utilities

 Transportation

 Other, specify _________________________________

 Don’t know/refused

Module: Other Information

1. Is there anything else you want to tell us related to the [chemical] incident?

That completes this survey. I would like to sincerely thank you for your time. Be sure to record the end time on the first page of this survey.