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1. What is your role in the community? (check all that apply)
   • Tribal Citizen [Insert Name of Tribal Nation here]
   • Tribal Citizen – another Tribal Nation (write in)
   • Tribal government employee
   • Community member (not enrolled)
   • Other(write in)

2. What is your race? (check all that apply)
   • American Indian/Alaska Native
   • Black or African American
   • Asian
   • Native Hawaiian or Other Pacific Islander
   • White
   • Other (write in)

3. What is your age (in years)? (choose one)
   • 18-24 years
   • 25-34 years
   • 35-44 years
   • 45-54 years
   • 55-64 years
   • 65- 74 years
   • 75-84 years
   • 85-94 years
   • 95+ years

4. What is your gender? (choose one)
   • Female
   • Male
   • Transgender female
   • Transgender male
   • Two Spirit
   • Non-binary
   • Other/Prefer not to say

5. What is your sexuality? (choose all that apply)
   • Asexual (little to no sexual attraction)
   • Bisexual (any form of attraction to two or more gender)
   • Demisexual (only experience sexual attraction after an emotional bond has formed)
   • Homosexual (lesbian or gay)
   • Heterosexual (straight)
   • Questioning
   • Other (write in)
   • Decline to answer

6. What is your marital status? (choose one)
   • Single
   • Married
   • Domestic partnership
   • Separated
   • Widowed
   • Divorced

7. To your knowledge, are you currently pregnant? (choose one)
   • Yes
   • No
   • Don’t know/ Not sure
   • Not Applicable

8. Where do you live? (check all that apply)
   • On reservation
   • In service area
   • Off reservation

9. Do you own or rent your home? (choose one)
   • Own
   • Rent
   • Don’t know/ Not sure

10. How many people live in your home on a regular basis? (number answer drop down)

Elders (over 65 years) __

Adults (18-64 years) __

Children (under 18 years) __

11. Are you a veteran? (choose one)
    • Yes
    • No

12. What is your current employment status? (check all that apply)
    • Employed full time
    • Employed part time
    • Unemployed - seeking employment
    • Unemployed - not seeking employment
    • Self-employed
    • Student
    • Retired
    • Caregiver/homemaker
    • Disability
    • Unable to work
    • Other

13. What is your annual personal income? (choose one)
    • Less than $10,000
    • $10,000 to $14,999
    • $15,000 to $24,999
    • $25,000 to $34,999
    • $35,000 to $49,999
    • $50,000 to $74,999
    • $75,000 to $99,999
    • $100,000 to $149,000
    • $150,000 to $199,999
    • $200,000 or more

14. What is your annual household income? (choose one)
    • Less than $10,000
    • $10,000 to $14,999
    • $15,000 to $24,999
    • $25,000 to $34,999
    • $35,000 to $49,999
    • $50,000 to $74,999
    • $75,000 to $99,999
    • $100,000 to $149,000
    • $150,000 to $199,999
    • $200,000 or more

15. What is your highest level of education? (choose one)
    • Never attended school
    • Elementary (Grades K-8)
    • Some High School (Grades 9-11)
    • High School Graduate (Grade 12 or GED)
    • Some college (1-3 years)
    • Associate degree
    • Technical/Trade school graduate
    • College graduate/Bachelor’s degree (4 years)
    • Master’s degree (MS, MPH, etc.)
    • Doctoral (PhD, JD, MD, etc.)

16. How much do you weigh (in pounds)? (number drop down options)

17. How tall are you (in feet and/or inches)? (number drop down options)

18. Do you currently have health insurance? (choose one)
    • Yes
    • No

19. What is the main source of your health insurance coverage(choose one)
    • Indian Health Service (IHS)
    • A plan through your employer
    • A plan through your spouse’s employer
    • A plan through the health insurance marketplace
    • A plan through your parents
    • Medicare
    • Medicaid
    • Tricare
    • Insurance plan through Veteran’s Affairs/ Champ VA
    • Other (please specify) (write in)
    • Uninsured

20. Within the last 2 years (since 2022), have you experienced any problems with your health insurance coverage? (choose one)

• Yes
• No

If “yes”, Please select the problem you experienced.

• Health insurance dropped (not due to change of employment)
• Health insurance denied somewhere it was previously accepted
• Trouble enrolling in government sponsored health insurance (Medicare, Medicaid)
• Aged out of parent’s health insurance coverage (turned 26 years old)
• Other (write in)

21. Have you or any member of your household ever received benefits from any of the following programs? (check all that apply)
    • Supplemental Nutrition Assistance Program (SNAP)
    • Women, Infants, and Children (WIC)
    • Medicaid
    • Medicare
    • Temporary Assistance for Needy Families (TANF)
    • Subsidized Housing, Housing Vouchers, and Public Housing Programs
    • Children’s Health Insurance Program (CHIP)
    • Supplemental Security Income Program (SSIP)
    • Head Start
    • None
    • Other (write in)

If any response other than none, --> Were any of these benefits offered to you through your Tribal Nation?

• Yes
• No

22. What is your primary form of transportation?(check all that apply)
    • Personal, owned vehicle
    • Borrowed vehicle from family/friends
    • Walking
    • Bicycle
    • Motorcycle
    • Public transportation (bus, train, etc.)
    • Tribal Nation provided transportation
    • Ride Share (Taxi, Uber, Lyft, etc.)
    • Tribal Nation provided transportation

23. What is your main form of transportation for medical appointments? (check all that apply)

• Personal, owned vehicle
• Borrowed vehicle from family/friend
• Walking
• Bicycle
• Motorcycle
• All-Terrain Vehicle (ATV)
• Hitch hike
• Public transportation (bus, train, etc.)
• Ride Share (Taxi, Uber, Lyft, etc.)
• Tribal Nation provided transportation

24. Do you have any physical or mental disabilities? (choose one)
    • Yes
    • No

25. Do you have animals? (choose one)
    • Yes
    • No

If yes, Which animals do you have? (check all that apply)

• Bird – Indoor (parrot, parakeet, etc.)
• Bird- Outdoor (chicken, ducks, etc.)
• Cat
• Cow
• Dog
• Fish
• Goat
• Horse
• Pig
• Reptile (snake, turtle, frog, etc.)
• Sheep
• Small animal/pocket pet (guinea pig, hamster, mouse, etc.)
• Other (write in)
• I do not have any animals

26. How strongly do you agree with the following statements? 

1. Within the last year have you used any of the following drugs/substances without a prescription from your medical provider? (check all that apply)

• Alcohol
• Marijuana
• Prescription Opioids
• Heroin
• Fentanyl
• Xylazine
• Stimulants (Cocaine, Adderall, etc.)
• Benzodiazepines (Xanax, Valium, Klonopin, etc.)
• Methamphetamines (Meth)
• Designer drugs (Ecstasy)
• Hallucinogens (LSD, Mushrooms, etc.)
• Inhalants (Aerosols, Nitrites, other solvents).
• Over the Counter Medication

2. How many alcoholic beverages do you consume in a week? (choose one)
   • <1 drink
   • 1-2 drinks
   • 3-4 drinks
   • 5 drinks
   • 5+ drinks

3. Substance misuse is a problem in my community. (choose one)

• Yes
• No

If select “yes” to substance misuse is a problem. What drugs and/or substances (alcohol) do you feel are being misused in your community? (check all that apply)

• Alcohol
• Marijuana
• Prescription Opioids
• Heroin
• Fentanyl
• Xylazine
• Stimulants (Cocaine, Adderall, etc.)
• Benzodiazepines (Xanax, Valium, Klonopin, etc.)
• Methamphetamines (Meth)
• Designer drugs (Ecstasy)
• Hallucinogens (LSD, Mushrooms, etc.)
• Inhalants (Aerosols, Nitrites, other solvents).
• Over the Counter Medication
• Other (write in)

4. Do you know anyone misusing substances in your community? (choose one)

• Yes
• No

5. Someone close to me has experienced an overdose. (choose one)

• Yes
• No

6. Someone close to me has died from an overdose. (choose one)

• Yes
• No

7. Have you ever, or do you currently inject drugs?  (choose one)
   • Yes
   • No

8. To your knowledge, have you ever gotten a tattoo or body piercing using an unsterilized and/or a previously used needle?(choose one)
   • Yes
   • No

9. Do you feel safe going on a walk/exercising around your neighborhood? (choose one)

• Yes
• No

10. Do you have access to parks or walkways near where you live? (choose one)

• Yes
• No

11. How supported do you feel by adults, church, community, and Tribal leaders/government in your life?(choose one)
    • Very supported
    • Supported
    • Somewhat supported
    • A little supported
    • Not supported

12. How often do you experience stress in your life?(choose one)
    • Very often
    • Often
    • Sometimes
    • Occasionally
    • Never

13. How supportive are members of your Tribal community regarding mental health conversations?(choose one)
    • Very supportive
    • Supportive
    • Somewhat supportive
    • A little supportive
    • Not supportive

14. How often do you feel treated unfairly based on your cultural identity?(choose one)
    • Very often
    • Often
    • Somewhat often
    • Occasionally
    • Never

1. How would you describe your current health status? (choose one)
   • Very good
   • Good
   • Fair
   • Poor
   • Very poor

2. How would you describe the overall health of your community? (choose one)
   • Very good
   • Good
   • Fair
   • Poor
   • Very poor

3. How do you rate your mental health (thoughts and emotions)? (choose one)
   • Very good
   • Good
   • Fair
   • Poor
   • Very poor

4. How important is your mental health to your quality of life? (choose one)
   • Very important
   • Important
   • Neither important nor unimportant
   • Unimportant
   • Very unimportant

5. How do you rate your physical health (your body)? (choose one)
   • Very good
   • Good
   • Fair
   • Poor
   • Very poor

6. How important is your physical health to your quality of life? (choose one)
   • Very important
   • Important
   • Neither important nor unimportant
   • Unimportant
   • Very unimportant

7. How do you rate your spiritual health (your religious or spiritual beliefs)? (choose one)
   • Very good
   • Good
   • Fair
   • Poor
   • Very poor

8. How important is your spiritual health to your quality of life? (choose one)
   • Very important
   • Important
   • Neither important nor unimportant
   • Unimportant
   • Very unimportant

9. How often in the last year have you felt lonely?(choose one)

• Very often
• Often
• Sometimes
• Occasionally
• Never

10. Not including ceremonial or sacred smoking, do you currently smoke/chew commercial tobacco products every day, some days or not at all? (choose one)
    • Every day
    • Some days
    • Not at all
    • Don’t know/Not sure

11. Not including yourself, how many of the people who live in your household smoke cigarettes, cigars, or pipes (non ceremonial)?(drop down number options)

12. During the past week, how many days were you physically active for at least 30 minutes per day? (choose one)
    • 1
    • 2
    • 3
    • 4
    • 5
    • 6
    • 7

13. In the past week, add up all the time you were physically active (ex. Heart rate increased, breathed hard)? (in minutes) (drop down number options)

14. On a normal day, how many hours do you spend playing with a smartphone or computer, watching TV or movies, or playing video games? (drop down number options)

15. How many hours of sleep do you normally get every night? (drop down number options)

16. How often do you spend time outside in the summer months?(choose one)
    • Very often
    • Often
    • Somewhat often
    • Occasionally
    • Never

17. On average, how long do you usually wash your hands?  (choose one)
    • Less than 5 seconds
    • 5 seconds
    • 10 seconds
    • 20 seconds
    • 30 seconds or greater

18. On average, how often do you brush your teeth? (choose one)
    • Twice a day
    • Once a day
    • A few times a week
    • Weekly
    • Periodically
    • Never

19. About how long do you spend brushing your teeth each time? (choose one)
    • Less than 20 seconds
    • 30 seconds
    • 1 minute
    • 2 minutes
    • 3 minutes

20. On average, how often do you floss your teeth?  (choose one)
    • Twice a day
    • Once a day
    • A few times a week
    • Weekly
    • Periodically
    • Never

21. How would you rate your eating habits?(choose one)
    • Excellent
    • Very Good
    • Good
    • Fair
    • Poor

22. In the last year, was there enough money for food for your household?  (choose one)
    • Yes
    • No
    • Don’t know/Not Sure

23. I can buy what I need at the grocery store for myself and my family.(choose one)
    • Yes
    • No
    • Sometimes

24. I can find fresh fruits and vegetables at my nearest supermarket. (choose one)
    • Yes
    • No
    • Sometimes

25. How far do you travel to get groceries?(choose one)
    • Less than 15 minutes
    • 16 minutes – 30 minutes
    • 31 minutes – 45 minutes
    • 46 minutes – 1 hour
    • More than 1 hour

26. For the following statements, please choose how often they are true.

27. Have you ever had a serious adverse reaction after a vaccine? (choose one)

A serious adverse event after vaccination includes the following: death, life-threatening illness, hospitalization or prolongation of hospitalization, permanent disability, congenital anomaly, or birth defect.

• Yes
• No
• Unsure

28. Do you feel comfortable/safe receiving vaccinations?(choose one)
    • Yes
    • No
    • Not sure

29. Do you believe vaccines are effective?(choose one)
    • Yes
    • No
    • Not sure

30. Check if you agree or disagree with the following statements.

1. What is your source for emergency information or alerts?(check all that apply)
   • Federal Emergency Management Agency (FEMA)
   • Local radio
   • National Weather Service
   • Newspapers
   • Social media
   • State Emergency Services Agency
   • Television
   • Tribal Emergency Services Agency
   • Tribal Leader/ Tribal Council
   • Tribal Nation’s social media
   • United South and Eastern Tribes, Inc. (USET)
   • Phone Call
   • Emergency Broadcast System
   • Other (write in)

2. In your home currently, do you have the following: (check all that apply)
   • Carbon monoxide detector
   • Fire extinguisher
   • Fire/smoke alarm
   • A generator

3. Check all the skills that you are confident in your ability to perform.(check all that apply)
   • Use a fire extinguisher
   • Administer CPR
   • Administer basic first aid
   • Administer Narcan/naloxone
   • Know how to shut off the gas in my home
   • Know how to shut off the electricity in my home
   • Know how to shut off the water in my home
   • Know what natural gas smells like
   • Know my family’s fire evacuation plan (where to go, where to meet)
   • Know all the exits in my home
   • Know how to prevent carbon monoxide poisoning
   • Memorized the number of my close family or friends
   • Memorized the number for local emergency services

4. In your home currently, do you have the following: (check all that apply) 
   • 7-day supply of all medications/medical items
   • Basic tool kit
   • Batteries
   • Battery powered/hand crank radio (NOAA Weather radio)
   • Cash
   • Cell phone with charger
   • Copies of personal documents (medication list, pertinent medical information, proof of address, deed/lease, passports, birth certificates, insurance policies)
   • Duct Tape
   • Emergency blanket
   • Extra set of car and house keys
   • First Aid Kit
   • Flashlight
   • Hand sanitizer, soap, disinfecting wipes
   • Manual can opener
   • Paper/printed map(s) of the area
   • Matches/lighter
   • Non-perishable, easy to prepare food items (3-day supply)
   • Pet supplies, medications, and documents
   • Three gallons of water per person/pet living in your household (lasts 3 day)
   • Whistle

5. When was the last time you tested your fire/smoke alarm?  (choose one)
   • Within the past week
   • Within the past month
   • Within the past 6 months
   • Within the past year
   • Within the past 2 years
   • I don’t remember
   • I have never tested it

6. When was the last time you tested your carbon monoxide alarm?(choose one)
   • Within the past week
   • Within the past month
   • Within the past 6 months
   • Within the past year
   • Within the past 2 years
   • I don’t remember
   • I have never tested it

7. Does your household have a current evacuation plan?(choose one)
   • Yes
   • No
   • Not sure

8. How safe do you feel in your home?(choose one)
   • Very safe
   • Safe
   • Somewhat safe
   • Not very safe
   • Not safe at all
   • I don't know/ Not sure

9. How safe do you feel in your neighborhood?(choose one)
   • Very safe
   • Safe
   • Somewhat safe
   • Not very safe
   • Not safe at all
   • I don't know/ Not sure

10. Do you and or your family have access to clean drinking water?(choose one)
    • Yes
    • No
    • Not sure

11. Where do you receive your drinking water? (check all that apply)
    • Well water
    • Municipal/City water
    • Tribal Nation water
    • Shipped in Water (ex. bottled water)
    • Other (write in)

12. Does your home have heat?(choose one)
    • Yes
    • No

If yes, what kind of heating? (check all that apply)

• Central Heating
• Radiator heating
• Wood furnace
• Other
• I do not know/ unsure

13. Does your home have air conditioning?(choose one)

• Yes
• No

14. Within the last year, have you ever slept: outside, in a car, in a tent, in an overnight shelter, or temporarily in someone else’s home NOT recreationally (i.e. couch-surfing)? (choose one)

• Yes
• No

15. Are you worried or concerned that in the next two months you may not have stable housing that you own, rent, or stay in as a part of a household? (choose one)

• Yes
• No

16. Are you currently unhoused?(choose one)
    • Yes
    • No

17. Does your household have access to the internet?(choose one)
    • Yes
    • No

18. How would you rate your quality of internet service?(choose one)
    • Very good
    • Good
    • Neutral
    • Bad
    • Very bad

19. From the list of health concerns listed below, rank the top 5 that you believe impact your community the most: (check all that apply)
    • Poor maternal, infant, and child health
    • Accidents (unintentional injuries)
    • Alcohol abuse
    • Substance abuse
    • Commercial tobacco use
    • Mental/emotional health issues
    • Suicide
    • Arthritis
    • Chronic pain
    • Diabetes
    • Obesity
    • Cancer
    • Heart disease
    • Stroke
    • Influenza/pneumonia
    • COVID-19
    • Tuberculosis
    • Liver disease/Cirrhosis
    • Lung disease
    • High blood pressure
    • High cholesterol
    • Sexually transmitted infections/diseases (STI/STD)
    • HIV/AIDS
    • Hepatitis C
    • Unplanned pregnancy
    • Immunizations
    • Domestic Violence
    • Poor elder health
    • Community/family connection
    • Sleep quality
    • Stress
    • Environmental issues impacting health
    • Historical trauma
    • Missing and Murdered Indigenous Women (MMIW) and Persons (MMIP)
    • Violence and trauma
    • Loneliness
    • Weather/natural disaster health impacts
    • Do not feel safe
    • Other (write in)

20. What makes it challenging to be healthy?(check all that apply)
    • Lack of access to clean and reliable water
    • Lack of access to fresh/healthy food options
    • Distance (community is rural, spread out)
    • Lack of transportation options
    • Limited access to medical care
    • Limited access to dental care
    • Limited access to eye care
    • Limited access to traditional medicine/healer
    • Limited access to affordable prescription medications
    • Access to health insurance coverage
    • Being away from the Tribal community
    • Lack of exercise facilities
    • Substance use
    • Low income/financial issues
    • Stress
    • Lack of access to healthcare/mental healthcare
    • Loss of family, friends, or community members
    • Other (Write in)

21. What does your community need to be healthier?(check all that apply)
    • More community connection, interaction, involvement, unity
    • Re-integration of traditional ways
    • Access to healthy foods/community gardens
    • Knowledge of health/healthy eating
    • Educational resources
    • Better access to resources and support services
    • Healing/speaking outlets, talking circles
    • Mental health programs
    • Financial resources/support
    • Better coordination of resources
    • Address the alcohol and drug issues

IHS 1

Charles Woodlee, CAPT (USPHS)

Director, Division of Environmental Health Services

Project TransAm & Emergency Preparedness Contact

Nashville Area IHS

Office of Environmental Health & Engineering

charles.woodlee@ihs.gov

Work: 615-208-3750

Cell: 615-568-7072

IHS 2

Charles Woodlee, CAPT (USPHS)

Director, Division of Environmental Health Services
Project TransAm & Emergency Preparedness Contact
Nashville Area IHS
Office of Environmental Health & Engineering
charles.woodlee@ihs.gov
Work: 615-208-3750
Cell: 615-568-7072

IHS 3

• Charles Woodlee, CAPT (USPHS)
  Director, Division of Environmental Health Services
  Project TransAm & Emergency Preparedness Contact
  Nashville Area IHS
  Office of Environmental Health & Engineering
  woodlee@ihs.gov
  Work: 615-208-3750
  Cell: 615-568-7072

FEMA (Region VI)

Dempsey Kraft

Tribal Affairs Section Chief;
Regional Tribal Liaison
202-258-1485
Dempsey.Kraft@fema.dhs.gov

Rachel Nutter (S. OK, E. TX, LA)

Tribal FIT Liaison
Rachel.Nutter@fema.dhs.gov
(940) 435-1663

Regional Tribal Affairs

800 N. Loop 288
Denton, TX 76209
fema-R6-tribal-affairs@fema.dhs.gov

BIA

Patrick Vacha

Deputy Chief
Indian Affairs Emergency Management
545 Marriot Drive
Suite 700
Nashville, TN 37214
202-577-5918
Patrick.vacha@bia.gov
*contact to join monthly BIA TAC-G call

Region: Southern Plains

Southern Plains Regional Office WCD Office Complex P.O. Box 368 (Physical: 1 Mile North on Hwy 281) Anadarko, OK 73005

Telephone: (405) 247-6673

Telefax: (405) 247-5611

Public Health Training Center Network

Region 6 South Central Public Health Training Center (R6-SCPHTC) (tulane.edu)

State Emergency Management

• Texas Department of Public Safety
• Contact List
• Texas Department of Emergency Management
• Contact List
• Regions by County
• Region 2 Contacts (Polk County)

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