CASPER Ice Storm
Area 1: Community Assessment for Public Health Emergency Response, KY, 2009
Date
mm-dd-yyyy
Cluster
##
Total HH in Cluster
###
Survey No.
###
Initials
Q1. Type of Structure
Single family house
multiple unit
mobile home
other
Select one
Q2. How many people lived in home before storm?
##
Q3. How many people slept in home last night?
##
3a. how many <=2?
##
3b. how many 3-17?
##
3c. how many 18-64?
##
3d. how many >=65?
##
Q4. Since storm, do you feel home is safe?
yes
no
dk
Select one
if not safe, why not?
Q5. Since the storm, do you feel secure?
yes
no
dk
Select one
if not secure, why not?
Q6. Was anyone in this house injured since storm?
yes
no
dk
Select one
if yes to to injured, specify below:
6a. Fall
yes
no
dk
Select one
number of fall
##
6b.strain/sprain
yes
no
dk
Select one
number strain/sprain
##
6c. Broken bone
yes
no
dk
Select one
number broken bone
##
6d.Head injury
yes
no
dk
Select one
number head injury
##
6e. cuts, abrasions, puncture wound
yes
no
dk
Select one
number of cuts, abrasion, puncture
##
6f. burns
yes
no
dk
Select one
number of burns
##
6g. CO poisoning
yes
no
dk
Select one
number of CO poisoning
##
6h. Hypothermia/cold injury
yes
no
dk
Select one
number of hypothermia
##
6i. Other
yes
no
dk
Select one
if other injury, specify
Q7. Has anyone in house become ill since storm?
yes
no
dk
Select one
if yes illness, specify below
7a. Nausea/stomachache/diarrhea
yes
no
dk
Select one
7b. Cough with fever
yes
no
dk
Select one
7c. Severe headache w/ dizziness
yes
no
dk
Select one
7d. worsened chronic illness
yes
no
dk
Select one
7e. Other
yes
no
dk
Select one
if other illness, specify
Q8. Since storm, is everybody getting prescription meds?
yes
no
dk
nh
Select one
if not getting meds, why not?
Q9. Is there anyone in home who needs:
oxygen supply
dialysis
home health care
other type
Select one
if other type of special care, specify
Q10. Since storm, emotional, anxiety, sleep or memory prob?
yes
no
dk
Select one
Q11. Do you have pets?
yes
no
dk
Select one
if yes to pets, did pet prevent you from seeking shelter?
yes
no
dk
Select one
Q12a. Do you have drinking water for next 3 days?
yes
no
dk
Select one
Q12b. What is present source of drinking water?
well
bottled
public municipal
no drinking water
Select one
Q12c. If using well or municipal water are you treating water?
no
yes-boiling
yes-chemical
dk
Select one
Q13. Do you have food for everyone for next 3 days?
yes
no
dk
nh
Select one
Q14. What is current source of electricity?
none
gasoline generator
power company
nh
Select one
Q15. Current source of heat?
electricity
propane gas
wood
coal charcoal
other
Select one
if other heat, specify
Q16. Since storm, used a generator?
yes
no
dk
Select one
If yes to generator, where and how do you use?
indoors
in garage
outside
Select one
if outside, how many ft from home?
##
if outside, near open door/window
yes
no
dk
Select one
Q17. Since storm, have cooked on grill or camp stove?
yes
no
dk
Select one
if yes to grill, where and how?
indoors with door window open
indoors with door window closed
outside
Select one
if outside, how many feet away?
##
if outside, near open door or window?
yes
no
dk
Select one
Q18. Do you have a carbon monoxide detector?
yes
no
dk
Select one
if yes to CO detector, is it working?
yes
no
dk
Select one
Q19. Do you have transportation?
yes
no
dk
nh
Select one
Q20. Do you have a working toilet?
yes
no
dk
nh
Select one
Q21. Do you have a working telephone?
yes
no
dk
nh
Select one
Q22. Did you get warning about the storm?
yes
no
dk
Select one
if yes to warning, what was the source?
TV
Radio
Flyer poster
neighbor
internet
newspaper
other
Select one
if other source, specify?
Q23. Have you gotten health advice related to storm?
yes
no
dk
Select one
if yes to advice, waht was source?
TV
Radio
Flyer poster
neighbor
internet
newspaper
other
Select one
if other advice, specify
Q24. Have you seen or heard warnings about CO poisoning?
yes
no
dk
Select one
Q25. Does anyone in home currently require urgent med care?
yes
no
dk
Select one
Q26. What is greatest need at this moment?
GeoLocation
Latitude
###.##############
Enter number between -90.0 and 90.0
Longitude
####.##############
Enter number between -180.0 and 180.0
GeoLocation Accuracy (m)
######.##
Altitude
########.##
Enter number greater than or equal to 0.0
Altitude Accuracy (m)
########.##
Enter number greater than or equal to 0.0
GeoLocation (Date/Time)
yyyy-mm-dd hh:mm:ss
Record Management Use Only
Global Record ID
(Read Only)
Record Is Completed
(Read Only)
Record Is Flagged
Record Create By
(Read Only)
Record Create (Date/Time)
(Read Only)
yyyy-mm-dd hh:mm:ss
Record Create Time Zone (UTC offset hours)
###.##
Enter number between -12.00 and 14.00
Record Latest Update By
(Read Only)
Record Latest Update (Date/Time)
(Read Only)
yyyy-mm-dd hh:mm:ss
Record Latest Update Time Zone (UTC offset hours)
###.##
Enter number between -12.00 and 14.00
Record Latest Update Notes
Record Update Log
(Read Only)
Record Comments
Data Not Saved