* Project	NC-4827 - RSP
* Today's Date (mm/dd/yyyy)

This anonymous form will help community leaders learn about needs in our community, and about how well the crisis counselors/outreach workers are meeting these needs. Please do not put your name on this form. If you filled out a form like this in the past week, please do not fill in this one. We thank you very much for your time!

How good of a job did the counselor or outreach worker do . . .
Treating you with respect?	Extremely poor Poor Fair Good Excellent
Respecting your culture, race, ethnicity, or religion?	Extremely poor Poor Fair Good Excellent
Making you feel that asking for help is okay?	Extremely poor Poor Fair Good Excellent
Making you feel that you can help yourself and your family?	Extremely poor Poor Fair Good Excellent
Keeping things you said private?	Extremely poor Poor Fair Good Excellent

Please indicate below which program services you have used. If you have used the service, please indicate whether or not it was helpful to you.	Have you used this service?	Was this service helpful?
One-to-one interaction (with counselor/outreach worker)	YES NO	YES NO
Public education presentation	YES NO	YES NO
Group counseling/support group	YES NO	YES NO
Handouts/materials	YES NO	YES NO
Internet sites (Crisis Counseling Assistance and Training Program [CCP] website, Facebook, etc.)	YES NO	YES NO
Other (please specify):	YES NO	YES NO
Referral resources	YES NO	YES NO

If you have used referral resources, which types(s) did you utilize?

Substance abuse	Community services (e.g., Federal Emergency Management Agency, loans, housing, employment, social services)
Mental health	Resources for those with disabilities or other access or functional needs
CCP services	Other referral type

If Other, specify in box

How good of a job did this program do with . . .
Helping you to know that your feelings after the disaster were the same as many other people's feelings?	Extremely poor Poor Fair Good Excellent
Helping you to find ways to take care of yourself, like eating right and getting enough sleep?	Extremely poor Poor Fair Good Excellent
Helping you to stay active in things like hobbies, sports, church, or volunteer work?	Extremely poor Poor Fair Good Excellent
In general . . .
How good was the information you got on how people feel after disasters?	Extremely poor Poor Fair Good Excellent
How good of an idea is it to tell a friend who was upset by the disaster to see this counselor or outreach worker?	Extremely poor Poor Fair Good Excellent
How useful was this program in helping return things in your life back to the way they were before the disaster?	Not at All Useful Slightly Useful Moderately Useful Very Useful Extremely Useful
Overall, how useful was this program to you?	Not at All Useful Slightly Useful Moderately Useful Very Useful Extremely Useful

People experience disasters in a variety of ways. Below is a list of experiences you may have had. Please select all that apply to you.

My family member is missing or dead.	My life or that of someone in my household was threatened.
My friend is missing or dead.	I or a member of my household witnessed death/injury.
My pet is missing or dead.	I or a member of my household assisted with rescue/recovery.
My home is damaged or destroyed.	I am or a member of my household is unemployed because of this disaster.
I had major property loss, such as car/vehicle loss.	I was evacuated quickly with no time to prepare.
I had other financial loss.	I had prolonged separation from family.
I or a member of my household was injured or physically harmed.	I was displaced from my home for 1 week or longer.

For the questions below, please share your reactions (feelings, emotions, and thoughts) about the disaster, considering your reactions in THE PAST MONTH. Using a scale of 1 to 5, where 1 is not at all, 2 is a little bit, 3 is somewhat, 4 is quite a bit, and 5 is very much, in the past month to what extent have you . . .

Been bothered by bad memories, nightmares, or reminders of what happened?	not at all a little bit somewhat quite a bit very much
Tried NOT to think or talk about what happened or to do things that remind you of what happened?	not at all a little bit somewhat quite a bit very much
Been bothered by poor sleep, poor concentration, feeling jumpy or angry, or being scared that something else bad will happen?	not at all a little bit somewhat quite a bit very much
Been down or depressed?	not at all a little bit somewhat quite a bit very much
Found other stressful things harder to deal with because of what happened?	not at all a little bit somewhat quite a bit very much
Had trouble taking care of your health (e.g., eating poorly, not getting enough rest, smoking more, drinking more)?	not at all a little bit somewhat quite a bit very much
Had difficulty getting along or having fun with family and friends?	not at all a little bit somewhat quite a bit very much
Needed help from a counselor to deal with your reactions to the disaster?	not at all a little bit somewhat quite a bit very much

Comparing your emotional and mental wellbeing before the disaster to now, do you feel better, worse, or about the same?

Feel better now

Feel about the same

Feel worse now

Comparing how well you take care of your health before the disaster to now, do you take care of your health better, worse, or about the same?

Take care of your health better now

Take care of your health about the same now

Take care of your health worse now

Comparing how well you work (including a job, schoolwork, and housework) before the disaster to now, do you have less trouble working, more trouble working, or about the same amount?

Have less trouble working now

Have about the same amount of trouble working now

Have more trouble working now

Comparing how active you were in things like hobbies, sports, church, or volunteer work before the disaster to now, are you more active, less active, or about the same?

More active now

About the same

Less active now

The final questions will help us to describe the total group of people who completed the form.

What is your sex?	Male Female
In what year were you born?

What is your annual gross household income?

< $10,000

$10,000 - $25,000

$25,000 - $40,000

$40,000 - $51,000

> $51,000

What is the highest level of education you have completed or degree you have received?

0 - 6 years	7 - 11 years
12 years (high school diploma or GED)	Some college
College graduate or more

In what county or parish do you currently live?

001 - Alamance 003 - Alexander 005 - Alleghany 007 - Anson 009 - Ashe 011 - Avery 013 - Beaufort 015 - Bertie 017 - Bladen 019 - Brunswick 021 - Buncombe 023 - Burke 025 - Cabarrus 027 - Caldwell 029 - Camden 031 - Carteret 033 - Caswell 035 - Catawba 037 - Chatham 039 - Cherokee 041 - Chowan 043 - Clay 045 - Cleveland 047 - Columbus 049 - Craven 051 - Cumberland 053 - Currituck 055 - Dare 057 - Davidson 059 - Davie 061 - Duplin 063 - Durham 065 - Edgecombe 067 - Forsyth 069 - Franklin 071 - Gaston 073 - Gates 075 - Graham 077 - Granville 079 - Greene 081 - Guilford 083 - Halifax 085 - Harnett 087 - Haywood 089 - Henderson 091 - Hertford 093 - Hoke 095 - Hyde 097 - Iredell 099 - Jackson 101 - Johnston 103 - Jones 105 - Lee 107 - Lenoir 109 - Lincoln 111 - McDowell 113 - Macon 115 - Madison 117 - Martin 119 - Mecklenburg 121 - Mitchell 123 - Montgomery 125 - Moore 127 - Nash 129 - New Hanover 131 - Northampton 133 - Onslow 135 - Orange 137 - Pamlico 139 - Pasquotank 141 - Pender 143 - Perquimans 145 - Person 147 - Pitt 149 - Polk 151 - Randolph 153 - Richmond 155 - Robeson 157 - Rockingham 159 - Rowan 161 - Rutherford 163 - Sampson 165 - Scotland 167 - Stanly 169 - Stokes 171 - Surry 173 - Swain 175 - Transylvania 177 - Tyrrell 179 - Union 181 - Vance 183 - Wake 185 - Warren 187 - Washington 189 - Watauga 191 - Wayne 193 - Wilkes 195 - Wilson 197 - Yadkin 199 - Yancey

Are you Hispanic/Latino?

YES NO

Which of the following best describes your race? (Please select all that apply.)

American Indian/Alaska Native	Asian
Black or African American	Native Hawaiian/Other Pacific Islander
White

What is your preferred language?

English

Spanish

Other

If Other, specify in box


If you have a disability, or other access or functional need, please indicate the type (select all that apply).

Physical (mobility, visual, hearing, medical, etc.)

Intellectual/Cognitive (learning disability, developmental delay, etc.)

Mental Health/Substance Abuse (psychiatric, substance dependence, etc.)