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2. Name
3. Email Address
5. Address
7. City
8. State
9. Zip Code
11. Phone Number
12. Job Title
16. Do you have natural gas pipelines running through your community?
18. Do you know the name of your local natural gas company?

    If yes, who?

20. Have you heard or seen a message regarding natural gas safety in the last 12 months?

    If yes, about how many?

22. Before today, about when was your last contact with someone from the natural gas industry related to pipeline safety?

    (If known, fill in approximate date or number of weeks, months, or years ago.)

24. Do you have the number to call in the natural gas company if there is an incident or you need more information?
26. Do you know who regulates the natural gas company in this State?

    (If no, they should be informed about it.)

28. Do you know the precautions an excavator should take prior to digging, to avoid accidentally hitting a natural gas pipeline?

    If yes, what are they?

30. Are you familiar with the one-call line (811)?
32. How would you rate the adequacy of information you have about natural gas safety (e.g., how to recognize a leak, what to do when there is a leak, what first responders should do, etc.)?

    1. About right
    2. Too much
    3. Not enough
34. Does your community have an emergency response plan to deal with a natural gas leak (regardless of whether intentional or accidental)?
36. Are you aware of any pipeline leaks that occurred in your community in the last 2 years?

    If yes, how many? What were they?

38. Have any of your local citizens or businesses expressed concern in the last 12 months about any issue regarding natural gas safety?

    1. Yes
    2. No
40. If yes, what was it?
42. Overall, do you feel the natural gas industry has an adequate public safety awareness program?

    1. Definitely yes
    2. Pretty much so
    3. Not sure
    4. Do not know
    5. Probably not
    6. Definitely not
44. Do you know how to contact the local natural gas company if there is an incident, or if you need more information?
46. Have you seen, heard, or received any information regarding natural gas safety in any media in the last year?

    If yes, do you recall when?

48. Do you have a response plan or SOPs for responding to a natural gas incident, such as a leak?
50. Have you done any practical training to deal with a leak?
52. Do you feel reasonably well prepared to deal with a natural gas leak, should one occur in your community?
54. If not, in what areas are there deficiencies?

    1. Training
    2. Special Equipment
    3. Knowledge about leaks
    4. Inherent dangers
    5. Other

    (Check all that apply.)

56. If other, please explain.
58. If you heard a report of a natural gas leak right now, what actions would you or your department take? [Write in the steps.]
60. Do you know if there were any natural gs leaks within the last two years in your community?
62. If yes, about when? What was the incident? Did the department respond?
64. If yes, Do you feel the department dealt with the incident in a satisfactory manner?
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