FEMA Form FF-104-F Preparedness Survey- Electronic

P reparedness Survey - Electronic

FEMA LOGO (TOP LEFT FIRST PAGE ONLY)

OMB Control Number 1660-0145

Expiration: xx/xx/xxxx

PAPERWORK BURDEN DISCLOSURE NOTICE:

Public reporting burden for this data collection is estimated to average 8 minutes per response. The burden estimate includes the time for reviewing instructions, searching existing data sources, gathering and maintaining the data needed, and completing and submitting this form. This collection of information is voluntary. You are not required to respond to this collection of information unless a valid OMB control number is displayed on this form. Send comments regarding the accuracy of the burden estimate and any suggestions for reducing the burden to: Information Collections Management, Department of Homeland Security, Federal Emergency Management Agency, 500 C Street, SW., Washington, DC 20472-3100, Paperwork Reduction Project (1660-0143) NOTE: Do not send your completed form to this address.

PRIVACY ACT STATEMENT

AUTHORITY: Government Performance and Results Act of 1993 (Pub. L. 103-62), as amended, and the GPRA Modernization Act of 2010 (Pub. L. 111-352); Executive Order (EO) 12862, “Setting Customer Service Standards”; and its March 23, 1995 Memorandum addendum, “Improving Customer Service”; Executive Order 13411 “Improving Assistance for Disaster Victims”; Executive Order 13571 “Streamlining Service Delivery and Improving Customer Service”; and the related June 13, 2011 Memorandum “Implementing Executive Order 13571 on Streamlining Service Delivery and Improving Customer Service.”

PRINCIPAL PURPOSE(S): DHS/FEMA collects this information to measure Individual Assistance applicants’ customer satisfaction with FEMA services.

ROUTINE USE(S): This information is used for the principal purpose noted above. Summary and/or aggregate survey results and analysis may be shared with Congress and the Government Accountability Office; however, no Personally Identifiable Information (PII) will be shared externally, except as allowed under the routine uses published in System of Records Notice DHS/FEMA-008 - Disaster Recovery Assistance Files, 78 FR 25282 (April 30, 2013), or as required by law. The Department's system of records notices can be found on the Department's website at http://www.dhs.gov/system-records-notices-sorns.

DISCLOSURE: The disclosure of information on this form is strictly voluntary and will assist FEMA is making improvements to its Individual Assistance program; failure to provide the information requested will not impact an individual’s ability to qualify for or receive FEMA Individual Assistance. Questions regarding this form may be submitted via email to FEMA-Program-Survey@fema.dhs.gov.

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Begin Survey

(Note for CSA-the below will be reformatted to include required screen/page breaks prior to loading into software).

DISASTER WARNINGS AND ACTIONS

This survey is related to the [Disaster Type] that occurred in [Disaster Month, Disaster Year]. Let’s start with some questions about how you found out what was happening and what actions you took.

Q1. Did you receive an advance warning about this disaster?

• Yes

• No

• Don’t Remember

Programmer Note: If Q1 response = Yes go to Q2 else go to Q4

Q2. Which of the following were sources for that advance warning: (Select all that apply)

• Television

• Radio

• Online publications

• Printed publications

• Social Media (Like Twitter, Instagram, Facebook)

• Smartphone App

• Personal contacts (Like friends, family, work, school)

• Local community notifications (Like siren, phone call, e-mail, text)

• Other

Q3. How far in advance did you receive a warning that you and your household might be impacted by the hazard?

• Less than 15 minutes

• From 15 minutes to less than 3 hours

• From 3 hours to less than 6 hours

• From 6 hours to less than 24 hours

• More than 24 hours

Q4. Did local authorities provide information or recommendations on actions you should take?

• Yes

• No

• Don’t Remember

Programmer Note: If Q4 response = Yes go to Q5 else go to Q8

Q5. Which of the following recommendations or information did local authorities provide: (Select all that apply)

• Evacuate

• Best routes to use when evacuating

• Roads to avoid due to flooding or dangerous conditions

• Move to a protected location (Like higher ground, storm shelter)

• Public shelter locations

• Shelter in place

• Consideration for contagious disease, pandemic, or other illness

• Consideration for household members with special needs

• Other

Q6. Did you take any actions based on the recommendation of local authorities?

• Yes

• No

• Don’t Remember

Programmer Note: If Q6 response = Yes go to Q7 else go to Q8

Q7. Which of the following actions did you take: (Select all that apply)

• Evacuated based on directions

• Stayed where you were at home, work, school, or other location

• Moved to a protected location

• Went to a shelter

• Went to stay with friends or family

• Went to a hotel/motel

• Other

DISASTER PREPAREDNESS INFORMATION

There are a variety of sources for obtaining information about what should be included in your emergency plans, such as, storing supplies you might need, how to protect yourself, and how to reduce property damages.

Q8. Before the disaster, did you look for information on how to prepare?

• Yes

• No

• Don’t Remember

Programmer Note: If Q8 response = Yes go to Q9 else go to Q10

Q9. Which of the following sources did you use to find information on how to prepare for disasters: (Select all that apply)

• Television

• Radio

• Online publications

• Print publications

• Social Media (Like Twitter, Instagram, Facebook)

• Smartphone App

• Personal contacts (Like friends, family, work, or school)

• Other

Q10. Did you receive any disaster preparedness training through your local government?

• Yes

• No

• Don’t Remember

Programmer Note: If Q10 response = Yes go to Q11 else go to Q12)

Q11. Which of the following best describes the advice given in the training: (Select all that apply)

• Sign up for alerts and warnings

• Make-a-plan

• Save for a rainy day

• Practice emergency drills

• Test Family Communication Plan

• Safeguard documents

• Plan with neighbors

• Assemble or update supplies

• Get involved in your community

• Make your home safer

• Know evacuation routes

• Document and insure property

• Other

Q12. Did you participate in any community planning hosted by your local government?

• Yes

• No

• Don’t Remember

Programmer Note: If Q12 response = Yes go to Q13 else go to Q14)

Q13. Was that community planning about any of the following: (Select all that apply)

• Preparedness

• Response

• Mitigation for hazards

• Long-term recovery

• Other

Q14. Please rate any advice you received on how to prepare using a scale of 1 (Not at all Useful) to 5 (Very Useful) or indicate you did not receive advise.

1 Not at all Useful	2	3	4	5 Very Useful	6 Did not receive any Advice
O	O	O	O	O	O

(Programmer Note: If Q14 response = 1 or 2 go to Q15 else go to Q16)

Q15. What changes are needed to make the advice more useful? (500 character max)

Q16. Which of the following are the best ways to provide you with information on how to protect your household and property from a disaster: (Select all that apply)

• Television

• Radio

• Online Publications

• Printed Publications

• Social Media (Like Twitter, Instagram, Facebook)

• Personal contacts (Like friends, family, work, school)

• Other

DISASTER READINESS – Immediate Needs

Please think back to the preparations you made for meeting immediate needs that would help you during the first few days after the disaster.

For these questions please use a rating scale of 1 (Not at all Prepared) to 5 (Fully Prepared).

Q17. Prior to the disaster happening, how would you have rated your level of preparation?

1 Not at all Prepared	2	3	4	5 Fully Prepared
O	O	O	O	O

Q18 After the disaster happened, how would you rate your actual level of preparation?

1 Not at all Prepared	2	3	4	5 Fully Prepared
O	O	O	O	O

(Programmer Note: If Q18 response = 1 or 2 go to Q19 else go to Q20)

Q19. Based on what you learned from this experience, which of the following supplies, equipment, and services did you need and not have: (Select all that apply)

• Safe drinking water

• Food

• Critical documents for identity, banking, insurance, etc.

• Plans for how to get in touch with family, friends, etc.

• Generator for emergency power

• Medication or medical supplies

• Cash

• Gasoline for vehicles or generator

• Utilities (Like water/gas/electric/phone/internet)

• Disability/Accessibility needs (Like wheelchair, hearing devices, etc.)

• Other

Q20. Using a rating scale of 1 (Very Unlikely) to 5 (Very Likely), how likely are you to take more steps to prepare for immediate needs in the future?

1 Very Unlikely	2	3	4	5 Very Likely
O	O	O	O	O

(Programmer Note: If Q20 response = 1 go to Q22 else go to Q21)

Q21. Before the next disaster, do you plan to take any of the following actions: (Select all that apply)

• Sign up for alerts and warnings

• Make-a-plan

• Save for a rainy day

• Practice emergency drills

• Test family communication plan

• Safeguard documents

• Plan with neighbors

• Assemble or update supplies

• Get involved in your community

• Make your home safer

• Know evacuation routes

• Document and insure property

• Other

DISASTER RECOVERY

Q22. The next questions relate to your progress in recovering from the impacts of this disaster. Using a rating scale of 1 (Not at all Recovered) to 5 (Completely Recovered), how would you rate your current level of recovery?

1 Not at all Recovered	2	3	4	5 Completely Recovered
O	O	O	O	O

(Programmer Note: If Q22 response = 1, 2, or 3 go to Q23 else go to Q24)

Q23. Which of the following are primary causes for delays in your recovery: (Select all that apply)

• Money for home repairs

• Money for personal property

• Money to move to a new residence

• Delayed or denied insurance settlement

• Delayed FEMA appeal

• Lack of affordable and/or accessible housing

• Lack of time to make repairs

• Lack of contractors and/or materials

• Medical or disability conditions

• Unemployed as a result of the disaster

Q24. Did you need but not have information on any of the following: (Select all that apply)

• Available rental housing

• Insurance coverage and claims

• Local contractors and repair services

• Local zoning, building codes and permits

• Disaster unemployment assistance

• Disaster loans from the Small Business Administration (SBA)

• Operational status of schools, colleges, etc.

• Available public transportation

• Locator services for finding displaced family and friends

Q25. What would help you the most to be ready for another disaster? (500 characters max)

DEMOGRAPHICS

Q26. We’re almost done. Would you volunteer to answer a few demographic questions for statistical purposes?

◘ Yes

◘ No

(Programmer Note: If Q26 response = Yes go to Q27, else go to Q36)

Q27. Is your gender…

◘ Female

◘ Male

◘ Other (e.g., transgender, nonbinary, or gender variant)

◘ Prefer not to answer

Q28. Is your age range…

◘ Under 25

◘ 25 to 34

◘ 35 to 44

◘ 45 to 54

◘ 55 to 64

◘ 65 to 74

◘ 75 or older

◘ Prefer not to answer

Q29. Is your marital status…

◘ Never married

◘ Married or living with partner

◘ Separated

◘ Widowed

◘ Divorced

◘ Prefer not to answer

Q30. Is your current employment status…

◘ Employed for wages

◘ Self-employed

◘ Unemployed

◘ Homemaker

◘ Student

◘ Retired

◘ Prefer not to answer

Q31. Which of the following best describes your highest level of formal education?

◘ Did not complete high school

◘ High school graduate / GED

◘ Some college

◘ Associate degree

◘ Bachelor’s degree

◘ Master’s degree

◘ Doctoral degree

◘ Prefer not to answer

Q32. Are You Hispanic or Latino? (A person of Cuban, Mexican, Puerto Rican, South or Central American, or other Spanish culture or origin, regardless of race.)

◘ Yes

◘ No

Q33. Please select the racial category or categories that you most closely identify with. Select as many as apply.

• American Indian or Alaska Native

• Asian

• Black or African American

• Native Hawaiian or Other Pacific Islander

• White

• Prefer not to answer

Q34. Do you or anyone in your household have a disability that affects your ability to carry out activities of daily living or requires an assistive device such as, but not limited to, a wheelchair, walker, cane, hearing aid, communication device, service animal, personal care attendant, oxygen or other similar medically-related devices or services?

◘ Yes

◘ No

(Programmer Note: If Q34 response = Yes go to Q35, else go to Q36)

Q35. Are the devices or services used to assist with any of the following? (You may select all that apply.)

• Mobility

• Cognitive, Developmental Disabilities, Mental Health

• Hearing and/or Speech

• Vision

• Self-Care

• Independent Living

• Other

Q36. Your opinion is very valuable to us. May we contact you later to ask additional questions?

◘ Yes

◘ No

Close

Thank you for your time.

FEMA Form FF-104-FY-21-181 (formerly 519-0-45)