HURRICANE FLORENCE EXPERIENCE SURVEY

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HURRICANE FLORENCE EXPERIENCE SURVEY

TO BE FILLED OUT BY ANYONE THAT EXPERIENCED HURRICANE FLORENCE
The Endependence Center (ECI) is a Center for Independent Living and we are looking for feed-back regarding your experience with Hurricane Florence specifically for people with disabilities. The information we gather from the Forum we are holding on October 17 from 10am to 11:30am at ECI, 6300 E Virginia Beach Blvd, Norfolk, VA 23502 and this questionnaire will be compiled into a report and submitted to emergency management and other interested parties. No personal contact information including name, address, email or phone will be shared unless you give consent. Please answer the following questions: NOTE: Items with an asterisk (*) are required.
QUESTIONNAIRE
*What city or county and state do you live in?
*Are you		A person with a disability A family member/friend of a person with a disability A caregiver Non-Disabled				Select one option.
*type of disability that you have						Hold Ctrl Key-select options
*Did you have any difficulty determining your evacuation zone?		YES NO N/A
*If yes to evacuation zone, please explain:
*Did you try to use public transportation to evacuate or go to a shelter, but were unable to?		YES NO
*If yes to public transportation to evacuate/shelter, please explain:
*If you were in a shelter, did you have difficulty returning home due to transportation?		YES NO N/A
*If yes to transportation home from shelter, please explain:
*Did you have a public transportation issue not related to evacuation or sheltering during Hurricane Florence?		YES NO
*If yes to public transportation issue, please explain:
*What was your decision as it relates to a safe location during Hurricane Florence?		Evacuated to a shelter Evacuated but stayed near my home (within 25 miles) Evacuated out of the area (more than 25 miles) Sheltered-in-Place (home)				Select one option
*How many people in your family evacuated with you?
*Fill in the name and address of the shelter you went to.
*Did you have any issues with accessiblity while at the shelter?		YES NO
*If yes to accessiblity issues in a shelter, please explain:
*Have you signed up with your city or county to receive their alerts?		YES NO
*Did you have any issues with receiving accessible updates through the media (TV/Radio/Alerts/Social Media)?		YES NO
*If yes to media accessiblity issues, please explain:
*Did you experience an electrical power outage?		YES NO
*How long was your electrical power out?						enter number of hours
*Did you experience any flooding?		YES NO
*If yes to flooding, please explain any issues encountered:
ADDITIONAL INFORMATION
*Did you receive information regarding preparation for the Hurricane before it came?		YES NO
*Would you like to receive emergency preparation information?		YES NO
Please provide any additional comments related to your experience with Hurricane Florence.
*Do you give consent for us to provide your contact information to emergency management to receive preparedness information?		YES NO
*Full Name
*Street Address
*City
*State
*Zip Code
Phone Number						No dots/dashes/parenthesis
Email Address
Thank you for taking the time to complete this survey about your experience with Hurricane Florence!
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