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* NAME:

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* DATE:

PART ONE

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* 1. Are you:

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* What is your primary method of receiving communication?

PART TWO

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* 1. Have you ever attempted to contact 911 in an emergency situation? If not, please skip to question 3.

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* a. Where were you located when you attempted to contact 911? Please specify the town/city, and county, if possible.

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* b. Were you able to communicate with the 911 operator? If not, please skip to question 2.

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* c. How did you communicate with the 911 operator? Did you use a relay service (TTY) or another method?

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* d. Did you have difficulty communicating with the 911 operator? If yes, please explain.

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* 2. If you attempted to contact 911 in an emergency situation, but were not able to communicate with the 911 operator, what was the result of your call? Was a police or emergency unit dispatched to your location?

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* 3.  Are you aware of the options available in your local area for contacting 911 in an emergency situation?

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* a. Have you ever attempted to send a text message to 911 in an emergency situation? If yes, what was the result, and where were you located at the time you sent the text message?

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* b. Have you asked anyone who works for the police, sheriff, government, or similar office in your area what your options are for contacting 911? If yes, who did you ask and what was their response?

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* b. Where is your current primary location? Please specify town/city, and county, if possible.

PART THREE

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* Please provide any other information you think is relevant in the space below. You may attach more pages if you need more space.

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