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Public Health Emergency Preparedness

This resource was part of AHRQ's Public Health Emergency Preparedness program, which was discontinued on June 30, 2011, in a realignment of Federal efforts.

This information is for reference purposes only. It was current when produced and may now be outdated. Archive material is no longer maintained, and some links may not work. Persons with disabilities having difficulty accessing this information should contact us at: https://info.ahrq.gov. Let us know the nature of the problem, the Web address of what you want, and your contact information.

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Appendix B. Needs Assessment Survey Forms

Appendix B1. Nurses Survey
Appendix B2. Crisis Team/Administration Survey
Appendix B3. Staff Survey

Appendix B1. Nurses Survey

The purpose of this survey is to gather information regarding your knowledge and concerns about disaster preparedness in your school. This survey will help construct a comprehensive and practical emergency plan. Your responses are confidential, and the compiled data will be shared with you. Thank you for taking the time to complete this survey. 

Demographic Information:

School ______________________

Numbers of years as a nurse in schools  _______

Gender ____   

Age Range:     ____ 30 or Under     _____ 31-40     _____ 41-50     ______ Greater than 50

Are you a parent? ______

1.  My school building is sufficiently secure and safe for staff and students.

____ Strongly agree     ____ Agree     ____ Neutral     ____ Disagree     ____ Strongly disagree

Comments: _________________________________________________________________

2.  I know what to do and what to say if I encounter a person in the building who is unfamiliar to me and is not properly identified as a visitor.

____ Strongly agree     ____ Agree     ____ Neutral     ____ Disagree     ____ Strongly disagree

Comments:  ___________________________________________________________________

3.  I am familiar with my town's Crisis Response Protocol.

____ Strongly agree     ____ Agree     ____ Neutral     ____ Disagree     ____ Strongly disagree

Comments: ____________________________________________________________________

4. I know the key members of my town's Disaster Response system and how the town would mobilize resources to my school in a disaster.

____ Strongly agree     ____ Agree     ____ Neutral     ____ Disagree     ____ Strongly disagree

Comments: ____________________________________________________________________

5. There is a competent Crisis Response Team in my building.

____ Strongly agree     ____ Agree     ____ Neutral     ____ Disagree     ____ Strongly disagree

Comments: ____________________________________________________________________

6.  The Crisis Response Team is sufficiently familiar with their specific responsibilities in the event of a disaster.

____ Strongly agree     ____ Agree     ____ Neutral     ____ Disagree     ____ Strongly disagree

Comments: ____________________________________________________________________

7. I have multiple contact numbers for all families in the event of an emergency.

____ Strongly agree     ____ Agree     ____ Neutral     ____ Disagree     ____ Strongly disagree

Comments: ____________________________________________________________________

8.  I know what to say to other students in my clinic if one of their classmates is seriously injured or ill.

____ Strongly agree     ____ Agree     ____ Neutral     ____ Disagree     ____ Strongly disagree

Comments: ____________________________________________________________________

9.  In the event of a crisis in which there were mass casualties, I would know who to call for support.  

____ Strongly agree     ____ Agree     ____ Neutral     ____ Disagree     ____ Strongly disagree

Comments: ____________________________________________________________________

10.  I have a system for the surveillance of communicable diseases so that I would recognize a trend in the school.

____ Strongly agree     ____ Agree     ____ Neutral     ____ Disagree     ____ Strongly disagree

Comments: ____________________________________________________________________

11. I know who to notify if there is a cluster of children in my building with similar symptoms.

____ Strongly agree     ____ Agree     ____ Neutral     ____ Disagree     ____ Strongly disagree

Comments: ____________________________________________________________________

12. I understand that there may be circumstances that would lead to an evacuation of the building to offsite locations. 

____ Strongly agree     ____ Agree     ____ Neutral     ____ Disagree     ____ Strongly disagree

Comments: ____________________________________________________________________

13. I know what my role would be if the building had to be evacuated.

____ Strongly agree     ____ Agree     ____ Neutral     ____ Disagree     ____ Strongly disagree

Comments: ____________________________________________________________________

14. In the event of a school evacuation, I know what I need to have with me and how I would transport it.

____ Strongly agree     ____ Agree     ____ Neutral     ____ Disagree     ____ Strongly disagree

Comments: ____________________________________________________________________

15.  My building plan includes specific accommodations for children with special medical and physical needs.

____ Strongly agree     ____ Agree     ____ Neutral     ____ Disagree     ____ Strongly disagree

Comments: ____________________________________________________________________

16.  I know the offsite locations where children with special medical needs will be relocated.

____ Strongly agree     ____ Agree     ____ Neutral     ____ Disagree     ____ Strongly disagree

Comments: ____________________________________________________________________

17. I think my building should have an annual evacuation drill.

____ Strongly agree     ____ Agree     ____ Neutral     ____ Disagree     ____ Strongly disagree

Comments: ____________________________________________________________________

18.  I think having an evacuation drill is potentially dangerous.

____ Strongly agree     ____ Agree     ____ Neutral     ____ Disagree     ____ Strongly disagree

Comments_____________________________________________________________________

19. I understand that there may be circumstances that would lead to a lockdown of the building (contain my students in a safe location within the school.) 

____ Strongly agree     ____ Agree     ____ Neutral     ____ Disagree     ____ Strongly disagree

Comments: ____________________________________________________________________

20. I know where to go with the children in my care if we had to lockdown the building.

____ Strongly agree     ____ Agree     ____ Neutral     ____ Disagree     ____ Strongly disagree

Comments: ____________________________________________________________________

 21. I think my building should have an annual lockdown drill.

____ Strongly agree     ____ Agree     ____ Neutral     ____ Disagree     ____ Strongly disagree

Comments: ____________________________________________________________________

22.  I do not believe students should be allowed to turn on cell phones in school, even if a local disaster has occurred.

____ Strongly agree     ____ Agree     ____ Neutral     ____ Disagree     ____ Strongly disagree

Comments: ____________________________________________________________________

23. I could recognize and comfort a child who is experiencing acute anxiety or post traumatic stress disorder. 

____ Strongly agree     ____ Agree     ____ Neutral     ____ Disagree     ____ Strongly disagree

Comments: ____________________________________________________________________

24. If a parent were to ask me about my school's plan for responding to different types of emergencies, I would know what to say.

____ Strongly agree     ____ Agree     ____ Neutral     ____ Disagree     ____ Strongly disagree

Comments: ____________________________________________________________________

25. I would like more information and training related to my school's Emergency Response Plan.

____ Strongly agree     ____ Agree     ____ Neutral     ____ Disagree     ____ Strongly disagree

Comments: ____________________________________________________________________

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Appendix B2. Crisis Team/Administration Survey

To:  Principals, Assistant Principals, and Members of the Crisis Response Teams:

The purpose of this survey is to gather information regarding the status of disaster preparedness in your school district. While we would all like to believe that we don't need to concern ourselves with these issues, today's reality belies that view. Our goal is to use the information that you and your staff provide to construct a comprehensive and practical Emergency Response Plan for your school. Your responses are confidential, and all data will be shared with you. Thank you for taking the time to complete this survey.

Demographic Information:

School _____________________________

Position:  ____ Principal      _____ Assistant Principal       _____ Crisis Response Team

Number of years in your school district  _________

Gender _______         

Age Range:  _____ 30 or Under    ____ 31-40     _____ 41-50     _____ Over 50

Are you a parent? ___________

1.  I feel that my building is sufficiently safe and secure for staff and students.

____ Strongly agree     ____ Agree     ____ Neutral     ____ Disagree     ____ Strongly disagree

Comments: ____________________________________________________________________

2.  All adults in the building who are not staff are identified in some way.

____ Strongly agree     ____ Agree     ____ Neutral     ____ Disagree     ____ Strongly disagree

Comments: ____________________________________________________________________

3.  My staff know what to do if there is an unidentified adult in the building.

____ Strongly agree     ____ Agree     ____ Neutral     ____ Disagree     ____ Strongly disagree

Comments: ____________________________________________________________________

4.  I am familiar with my district's Crisis Response Protocol.

____ Strongly agree     ____ Agree     ____ Neutral     ____ Disagree     ____ Strongly disagree

Comments: ____________________________________________________________________

5.  I know the key members of my district's Disaster Response system and how the town would mobilize resources to my school in a disaster.

____ Strongly agree     ____ Agree     ____ Neutral     ____ Disagree     ____ Strongly disagree

Comments: ____________________________________________________________________

6.  We have formed a competent Crisis Response Team in my building.

____ Strongly agree     ____ Agree     ____ Neutral     ____ Disagree     ____ Strongly disagree

Comments: ____________________________________________________________________

7.  The Crisis Response Team is sufficiently familiar with their specific responsibilities in the event of a disaster.

____ Strongly agree     ____ Agree     ____ Neutral     ____ Disagree     ____ Strongly disagree

Comments: ____________________________________________________________________

8.  I would like support in training my Crisis Response Team.

____ Strongly agree     ____ Agree     ____ Neutral     ____ Disagree     ____ Strongly disagree

Comments: ____________________________________________________________________

9.  I have good communication with Town Safety Officers.

____ Strongly agree     ____ Agree     ____ Neutral     ____ Disagree     ____ Strongly disagree

Comments: ____________________________________________________________________

10.  My staff are familiar with my district's Crisis Response Protocol.

____ Strongly agree     ____ Agree     ____ Neutral     ____ Disagree     ____ Strongly disagree

Comments: ____________________________________________________________________

11.  My staff know where to go with their students if the building has to be evacuated.

____ Strongly agree     ____ Agree     ____ Neutral     ____ Disagree     ____ Strongly disagree

Comments: ____________________________________________________________________

12.  My staff know what they need to have with them if they have to evacuate the building with their students.

____ Strongly agree     ____ Agree     ____ Neutral     ____ Disagree     ____ Strongly disagree

Comments: ____________________________________________________________________

13.  My staff know where to go if there is a lockdown in the building.

____ Strongly agree     ____ Agree     ____ Neutral     ____ Disagree     ____ Strongly disagree

Comments: ____________________________________________________________________

14.  I would like some support in training my staff to respond appropriately to disasters.

____ Strongly agree     ____ Agree     ____ Neutral     ____ Disagree     ____ Strongly disagree

Comments: ____________________________________________________________________

15.  The parents in my school are familiar with our building's Emergency Response Protocol.

____ Strongly agree     ____ Agree     ____ Neutral     ____ Disagree     ____ Strongly disagree

Comments: ____________________________________________________________________

16.  I have multiple contact numbers for all families in the event of an emergency.

____ Strongly agree     ____ Agree     ____ Neutral     ____ Disagree     ____ Strongly disagree

Comments: ____________________________________________________________________

17.  I do not believe students should be allowed to turn on cell phones in school, even if a local disaster has occurred.

____ Strongly agree     ____ Agree     ____ Neutral     ____ Disagree     ____ Strongly disagree

Comments: ____________________________________________________________________

18.  We should have an annual evacuation drill in our schools.

____ Strongly agree     ____ Agree     ____ Neutral     ____ Disagree     ____ Strongly disagree

Comments: ____________________________________________________________________

19.  We should have an annual lockdown drill in our schools.

____ Strongly agree     ____ Agree     ____ Neutral     ____ Disagree     ____ Strongly disagree

Comments: ____________________________________________________________________

20.  We have a sufficient number of fire drills.

____ Strongly agree     ____ Agree     ____ Neutral     ____ Disagree     ____ Strongly disagree

Comments: ____________________________________________________________________

21.  My staff know what to say to their students about disaster preparedness.

____ Strongly agree     ____ Agree     ____ Neutral     ____ Disagree     ____ Strongly disagree

Comments: ____________________________________________________________________

22.  My building plan includes specific accommodations for children with special medical and physical needs.

____ Strongly agree     ____ Agree     ____ Neutral     ____ Disagree     ____ Strongly disagree

Comments: ____________________________________________________________________

23. I know where I can get support to help children who express acute anxiety or post traumatic stress disorder.

____ Strongly agree     ____ Agree     ____ Neutral     ____ Disagree     ____ Strongly disagree

Comments: ____________________________________________________________________

24.  The Extended Day Program in my building is familiar with my district's Crisis Response Protocol.

____ Strongly agree     ____ Agree     ____ Neutral     ____ Disagree     ____ Strongly disagree

Comments: ____________________________________________________________________

Top of Page

Appendix B3. Staff Survey

To: School Staff (Teachers, Administrative staff):

The purpose of this survey is to gather information regarding your knowledge and concerns about disaster preparedness in your school district. This survey will inform us in constructing a comprehensive and practical emergency plan. Your responses are confidential, and the compiled data will be shared with you. Thank you for taking the time to complete this survey. 

Demographic Information:

School ______________________

Staff Position:    ___ Teacher   ____ Aide or Intern     ___ Support Staff  

Grades I teach: ____ K-2       _____ 3-5    ______ 6-8  _______ 9-12 (check all that apply)

Numbers of years as a staff person in your school district  _______

Gender ____   

Age Range:     ____ 30 or Under      _____ 31-40     _____ 41-50     ______ Greater than 50

Are you a parent? ______

1.  I know which staff in my building are on the Crisis Response Team, and I know the Team's responsibilities.

____ Strongly agree     ____ Agree     ____ Neutral     ____ Disagree     ____ Strongly disagree

Comments: ____________________________________________________________________

2.  I would know what to do, where to go, and what to say to my students if there were an emergency in which I had to evacuate the building with my class.

____ Strongly agree     ____ Agree     ____ Neutral     ____ Disagree     ____ Strongly disagree

Comments: ____________________________________________________________________

3.  I would know what to do, where to go, and what to say to my students if there were an emergency in which I had to contain my students in the school building. (i.e., "shelter in" or "lockdown")

____ Strongly agree     ____ Agree     ____ Neutral     ____ Disagree     ____ Strongly disagree

Comments: ____________________________________________________________________

4.  If a parent were to ask me about the school's plan if the building had to be evacuated or locked down, I would be able to explain the protocol.

____ Strongly agree     ____ Agree     ____ Neutral     ____ Disagree     ____ Strongly disagree

Comments: ____________________________________________________________________

5.  If a student in my class is seriously injured, I know what to do as a first responder and how to get help.

____ Strongly agree     ____ Agree     ____ Neutral     ____ Disagree     ____ Strongly disagree

Comments: ____________________________________________________________________

6.  I have access to student medications and parent contact numbers.

____ Strongly agree     ____ Agree     ____ Neutral     ____ Disagree     ____ Strongly disagree

Comments: ____________________________________________________________________

7.  I think it would be useful to practice lockdown (containing the children in the classroom or in a predetermined location) and evacuation (leaving the building, with your class to a predetermined site.)

____ Strongly agree     ____ Agree     ____ Neutral     ____ Disagree     ____ Strongly disagree

Comments: ____________________________________________________________________

8.  If my school were to have a lockdown drill, I would know what to say to my students to prepare them for it.

____ Strongly agree     ____ Agree     ____ Neutral     ____ Disagree     ____ Strongly disagree

Comments: ____________________________________________________________________

9.  If my school were to have an evacuation drill, I would know what to say to my students to prepare them for it.

____ Strongly agree     ____ Agree     ____ Neutral     ____ Disagree     ____ Strongly disagree

Comments: ____________________________________________________________________

10.  If children seem particularly frightened by a lockdown or evacuation drill, I could recognize it and would know what to say to attempt to alleviate the fear.

____ Strongly agree     ____ Agree     ____ Neutral     ____ Disagree     ____ Strongly disagree

Comments: ____________________________________________________________________

11.  I would know how to inform parents about these drills and how to help them talk to their children if necessary.

____ Strongly agree     ____ Agree     ____ Neutral     ____ Disagree     ____ Strongly disagree

Comments: ____________________________________________________________________

12.  My school building is sufficiently secure and safe for staff and students.

____ Strongly agree     ____ Agree     ____ Neutral     ____ Disagree     ____ Strongly disagree

Comments: ____________________________________________________________________

13.  I know what to do and what to say if I encounter a person in the building who is unfamiliar to me and is not properly identified as a visitor.

____ Strongly agree     ____ Agree     ____ Neutral     ____ Disagree     ____ Strongly disagree

Comments: ____________________________________________________________________

14.  I know how to contact the parents in my class in cases of emergency.

____ Strongly agree     ____ Agree     ____ Neutral     ____ Disagree     ____ Strongly disagree

Comments: ____________________________________________________________________

15.  I know where to go with the children in my care in a fire drill.

____ Strongly agree     ____ Agree     ____ Neutral     ____ Disagree     ____ Strongly disagree

Comments: ____________________________________________________________________

16.  I know what to say to my students about the need for fire drills.

____ Strongly agree     ____ Agree     ____ Neutral     ____ Disagree     ____ Strongly disagree

Comments: ____________________________________________________________________

17.  I think my building has a sufficient number of fire drills.

____ Strongly agree     ____ Agree     ____ Neutral     ____ Disagree     ____ Strongly disagree

Comments: ____________________________________________________________________

18.  I could recognize a child who is experiencing acute anxiety or post traumatic stress disorder. 

____ Strongly agree     ____ Agree     ____ Neutral     ____ Disagree     ____ Strongly disagree

Comments: ____________________________________________________________________

19.  If a parent were to ask me about my school's plans for responding to different types of emergencies, I would know what to say.

____ Strongly agree     ____ Agree     ____ Neutral     ____ Disagree     ____ Strongly disagree

Comments: ____________________________________________________________________

20. I would know what to say to the students in my class if one of their classmates or a family member died or had a serious illness.

____ Strongly agree     ____ Agree     ____ Neutral     ____ Disagree     ____ Strongly disagree

Comments: ____________________________________________________________________

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