We conducted the study in Carroll, Dorchester, and Harford county health departments between March 2005 and July 2005. All three health departments are located in Maryland, and range in size from 132 employees to 225 employees. We selected these health departments because of their location in communities ranging from 30,000 on Maryland's Eastern Shore (Dorchester County) to 235,000 in the greater Baltimore/Towson metropolitan area (Harford County) [11] , thus reflecting the 96% of the nation's local public health agencies serving communities with populations of 500,000 or fewer [12] . Self-administered anonymous surveys were sent to all health department personnel by their respective health departments. Completed surveys were directly mailed to investigators at the Johns Hopkins Center for Public Health Preparedness.