[Directions: Insert information for COIN Telephone Surveys in the following template. Fill in our agency name and representative where indicated.]
Sample Telephone Survey Template
Hello, my name is ______________________.  I am with _____________________.
We are conducting a brief survey to help us define our at-risk populations. The survey should take about 15 minutes. Do you have time now or should I call you again at a later time? (If later, schedule a time to call).
We are collecting information to help us locate and reach at-risk populations with health care and emergency preparedness information.
Let’s begin the survey.
1.	What distinguishes the community you live in from others in the nation or state? 
	
2.	How would you define at-risk populations? 
	
3.	Who are the at-risk populations in the community? 
	
4.	What population trends are occurring in the community that might impact at-risk population groups?
	
5.	What is the primary language spoken in the community?  
	
What other languages are prevalent? 
	
6.	What populations are served by your agency/organization? 
	
7.	Who are the leaders, spokespersons, trusted sources, and key informants for at-risk populations in the community? 
	
8.	What are non-traditional information sources in the community that need to be tapped to provide more insight into who is at-risk, has barriers to communication, or is hard to reach? 
	
9.	Which populations are easiest to reach? 
	
10.	Which populations are the hardest to reach?  
	
Why?
	
11.	What is the biggest gap in communicating with at-risk populations? 
	
12.	In the event of a public health emergency, which populations would be most at-risk of not receiving critical information?  
	
Which would lack the means to act on the information? 
	
13.	What are the most common methods of sharing information with members of the group (e.g., written materials, radio, in-person conversations)? 
	
14.	On average, what is the highest level of education achieved by most members of the group? 
	
Thank you for your time and answers. Goodbye.

This survey was prepared by: __________________________________________ on (date)__________