6200-05 Initial Survey

 OMB Control No. 2050-XXXX
 Approval expires XX/XX/XX

Dear Partners,

The U.S. Environmental Protection Agency (EPA) is soliciting feedback from Partners on their experiences and suggestions under the Schools Chemical Cleanout Campaign (SC3). On an annual basis, we will ask Partners to participate in the SC3 Survey. The survey helps us learn about your accomplishments and the impacts being made in schools, so this can be shared with others through tools like the SC3 Web site. It also helps us identify needs and concerns that you have and how best to address them. Finally, it helps us determine the future direction of the Program.

We have created two survey forms, as follows:

• Initial Survey. This survey form should be completed by Partners who are participating in the SC3 Survey for their first time. It is designed to give us a general idea of a Partner’s background, accomplishments, and needs under SC3. The survey should be completed only for the first year of a Partner’s participation in the SC3 Program.

• Annual Update. Partners should complete an Annual Update in each subsequent year of their partnership. The Annual Update is designed to describe a Partner’s accomplishments and needs since the previous survey.

Enclosed with this letter is the Initial Survey. It is organized as follows:

• Part 1 asks for general information about your company (e.g., how you became aware of the SC3 Program).

• Part 2 asks for information on the services and resources that your company has provided to schools (e.g., support on chemical inventories, etc.).

• Part 3 asks for lessons learned under the Program (e.g., your successes and barriers to success) that can be shared with others. Part 3 also asks about your future involvement under the Program.

• Worksheets are attached at the end of the survey to help you provide some responses.

Each question in the survey includes brief instructions on how to provide a response. Please enter your responses electronically into the spaces provided on the form. If additional space is needed, please attach additional pages. We also would welcome any of your work products that can be shared with others (e.g., training materials that you developed).

Surveys should be submitted to EPA no later than September 30^th of each year by any of the following methods:

1. Emailed to: [email protected].

2. Faxed to: 703-308-1561 (c/o Cynthia Merse).

2. Special delivery (e.g., FedEx) to:

Cynthia Merse, N-5932

Two Potomac Yard
2733 S. Crystal Drive
Arlington, VA 22202

If you have any questions about the survey, please contact Cynthia Merse at EPA by phone (703-308-0020) or e-mail ([email protected]). Thanks in advance for your timely completion of the survey.

Sincerely,

Matt Hale

Director, Office of Resource Conservation and Recovery

Enclosure

INITIAL SURVEY:

SCHOOLS CHEMICAL CLEANOUT CAMPAIGN (SC3)

Instructions: Please review and complete Parts 1-3 and the worksheets of this survey. You should complete this survey to reflect your company’s experiences and accomplishments since joining the SC3 Program. Note that some of the questions and worksheets may not apply to your company. If so, please skip them.

Please provide your company name, the name of a contact person, and the person’s telephone number. In addition, indicate the date that this survey is submitted to EPA.

Company name:      

Contact person name:      

Contact person phone number:      

Date:      

PART 1: GENERAL INFORMATION ON PARTNER

1.1 How did your company become aware of the SC3 Partner Program? (Check all that apply.)

SC3 Web site

Schools/school districts

Trade organization

Newsletter or other print media

Conference or exhibition

Word of mouth

Other, please specify:      

1.2 Why did your company choose to become involved in SC3 activities? Please review the possible reasons for joining SC3 in the table. Place an “X” in the appropriate box to indicate the relevance of each reason based on a 1 to 5 scale (1 means “completely irrelevant” and 5 means “highly relevant”).

Possible Reasons for Joining SC3	Relevance to Your Company
	1 (Completely irrelevant)	2	3	4	5 (Highly relevant)
Enhance your company’s relationship with the community
Carry out the organizational mission or responsibility of your company
Establish new business relationships (e.g., business development)
Enhance existing business relationships
Other, please specify:      

1.3 Has your company conducted chemical inventories, cleanouts and/or other chemical management activities at schools prior to your involvement with SC3?

Yes

No

1.4 Please complete the table below to identify all of the schools that your company has supported under SC3 since joining the Program (e.g., support in chemical inventories, chemical management, training, chemical cleanouts). To do so, please complete items A and B as applicable:

A. Please identify the school(s) by name in Column 1 of the table. Note: If you wish to protect the identity of the school(s), you may assign each school a unique identifier (e.g., “School A,” “School B,” etc.) instead of providing their names.

B. For schools that are assigned a unique identifier: Please complete Columns 2 and 3 by indicating the approximate number of students and staff in each school. Information on student enrollment may be available on-line.

1. Name or Unique Identifier of Schools	2. Number of Students*	3. Number of Staff*
     	     	     
     	     	     
     	     	     
     	     	     
     	     	     
     	     	     
     	     	     
     	     	     
     	     	     
     	     	     

* These columns should be completed only for schools that are assigned a unique identifier.

1.5 Has your company used contractors/consultants to support schools in the following areas? (Check all that apply.)

Chemical inventories

Training/education

Chemical management program

Chemical cleanout/removal

Outreach

Other, please specify:      

Contractors/consultants have not been used at all

1.6 How many hours and dollars has your company spent in providing services and resources to schools since joining the Program? Please provide your response in Worksheet 1 at the end of this survey.

1.7 Has your company encouraged other companies or associations to join SC3? If you select “No,” please briefly explain why not.

Yes

No

     

1.8 Has your company encouraged schools to join SC3? If you select “No,” please briefly explain why not.

Yes

No

     

1.9 Does your company partner with EPA in any other Partnership Program(s)? (Check all that apply.)

WasteWise

National Partnership for Environmental Priorities (NPEP)

Other, please specify:      

PART 2: DESCRIPTION OF SERVICES AND RESOURCES PROVIDED

2.1 Chemical Inventory

2.1.1 Has your company performed a chemical inventory at a school since joining the Program? If you select “Yes,” please complete the remainder of this section. If you select “No,” skip to section 2.2.

Yes

No

2. Please identify the schools that have received support in chemical inventories from your company since joining the Program. List them by name or unique identifier (as assigned in Question 1.4) in the table below.

     

     

     

     

     

2.1.3 Were any of the schools identified in Question 2.1.2 performing chemical inventories prior to your involvement with them? If you select “Yes,” please use the additional space below to describe how your involvement improved the chemical inventories (e.g., what actions did you take and what improvements resulted from them, such as more thorough or frequent inventories, etc.?).

Yes

No

     

2.1.4 What chemical inventory activities has your company supported schools in developing, implementing, and/or funding since joining the Program? (Check all that apply.) Note: If you performed a walk-through of a school and inspected for chemicals, please answer Question 2.1.5. If you did not, please skip to Question 2.1.6.

Identified possible locations of chemicals before walk-through/inspection

Performed walk-through/inspection of all relevant locations for chemicals

Addressed safety hazards during walk-through/inspection (e.g., developed a plan to prevent and clean up spills)

Documented chemicals found

Established a sustainable chemical inventory program (i.e., a permanent program)

Other, please specify:      

2.1.5 If you performed a walk-through of a school and inspected for chemicals, which locations did you inspect? (Check all that apply.)

 

Science laboratories

Art classrooms

Vocational shops

Maintenance areas

Cleaning closets

Stockrooms/supply areas

Other, please specify:      

2.1.6 What chemicals have you assisted in inventorying since joining the Program? Please provide your response in Worksheet 2 at the end of this survey.

2.1.7 If your company encountered unknown chemicals during the inventory process, what actions did you take in addressing them during the inventory? (Check all that apply.)

Tested unknowns before offsite shipment

Used non-testing methods to characterize unknowns (e.g., by interviewing faculty)

Did not characterize unknowns before offsite shipment

Removed unknowns to a safe location pending offsite shipment

Other, please specify:      

Did not encounter unknowns

2.2 Training and Education

2.2.1 Has your company assisted in providing training or education at a school since joining the Program? If you select “Yes,” please complete the remainder of this section. If you select “No,” please skip to section 2.3.

Yes

No

2. Please identify the schools that have received training/education support from your company since joining the Program. List them by name or unique identifier (as assigned in Question 1.4) in the table below.

     

     

     

     

     

2.2.3 Were any of the schools identified in Question 2.2.2 performing such training/education prior to your involvement with them? If you select “Yes,” please use the additional space below to describe how your involvement improved the training/education (e.g., what actions did you take and what improvements resulted from them, such as a greater frequency of training, use of better training materials, coverage of new subject matter, etc.?).

Yes

No

     

2.2.4 Please describe your training/education (e.g., recipients and frequency of

trainings) by completing Worksheet 3 at the end of this survey.

2.2.5 What types of training has your company supported schools in developing, delivering and/or funding since joining the Program? Please review the table below to see if you have supported any of the types of trainings listed. If you have, please approximate the cumulative duration (in hours) of that training. For example, if you provided five two-hour classroom trainings, you would enter “10 hours” into the shaded cell for classroom training. Note: If you have not provided a type of training shown in the table, enter “N/A” into its shaded cell.

Types of Training:	Length of Training (hrs):
Classroom training	     
Emergency exercises (e.g., evacuation exercises)	     
On-the-job training (e.g., for faculty, maintenance staff)	     
Other, please specify:      	     

2.2.6 Has your company assisted in developing a sustainable training program for schools (i.e., a training program that will be conducted on a permanent basis by the school)? If you select “No,” please briefly explain if you plan to in the future.

Yes

No

     

2.3 Chemical Management Program

2.3.1 Has your company assisted in developing a chemical management program for a school since joining the Program? If you select “Yes,” please complete the remainder of this section. If you select “No,” please skip to section 2.4.

Yes

No

2. Please identify the schools that have received chemical management program support from your company since joining the Program. List them by name or unique identifier (as assigned in Question 1.4) in the table below.

     

     

     

     

     

2.3.3 Were any of the schools identified in Question 2.3.2 implementing a chemical management program prior to your involvement with them? If you select “Yes,” please use the additional space below to describe how your involvement improved the program (e.g., what actions did you take and what improvements resulted from them, such as the addition of new operating procedures or practices to address a need at the school, etc.?).

Yes

No

     

2.3.4 What elements of a chemical management program did your company help schools to develop, implement, and/or fund? (Check all that apply.)

Purchasing of chemicals (e.g., how to purchase fewer and/or less toxic chemicals)

Chemical inventory

Storage of chemicals

Chemical usage (e.g., changes in a school’s laboratory practices to minimize the quantity of chemicals used in experiments)

Regulatory compliance

Chemical waste collection, onsite storage and disposal

Labeling

Budgeting for chemical management

Training

Safety

Development/implementation of school policies, plans and/or procedures on proper chemical management

Development/implementation of performance goals and measures to gauge chemical management success

Grant writing

Use of “green cleaning” practices (e.g., using less-toxic cleaning products, cleaning when the building is unoccupied)

Other, please specify:      

2.4 Packaging, Removing and Disposing of Chemical Waste

2.4.1 Has your company assisted in packaging, removing and/or disposing of a school’s chemical waste (i.e., chemical cleanouts) since joining the Program? If you select “Yes,” please complete the remainder of this section. If you select “No,” please skip to section 2.5.

Yes

No

2. Please identify the schools that have received support in chemical cleanouts from your company since joining the Program. List them by name or unique identifier (as assigned in Question 1.4) in the table below.

     

     

     

     

     

2.4.3 Were any of the schools identified in Question 2.4.2 cleaning out their chemicals prior to your involvement with them? If you select “Yes,” please use the additional space below to describe how your involvement improved the cleanouts (e.g., what actions did you take and what improvements resulted from them, such as more frequent or thorough cleanouts, etc.?).

Yes

No

     

2.4.4 If one or more of the school(s) in Question 2.4.2 had not removed the chemicals on its own prior to your involvement, why not? (Check all that apply.)

School was not aware of the problem or need

School lacked the technical expertise/personnel

School lacked the financial resources

There was resistance within the school

Other, please specify:      

Not applicable

2.4.5 What chemical cleanout activities has your company supported schools in developing, performing, and/or funding since joining the Program? (Check all that apply.)

Collecting the chemical waste from individual rooms in the school

Performing testing/characterization of chemical waste

Packaging the chemical waste for offsite shipment

Storing the chemical waste prior to offsite shipment

Preparing required paperwork, if any (e.g., shipping paper)

Other, please specify:      

2.4.6 How often have you supported the school(s) in performing chemical cleanouts on average?

Once

Monthly

Semi-annually

Annually (e.g., at the beginning or end of the school year)

Other, please specify:      

2.4.7 What chemicals and other wastes have you assisted in cleaning out since joining the Program? Please provide your response in Worksheet 4 at the end of the survey.

2.5 Outreach/Communication

2.5.1 Has your company engaged in outreach/communication in connection with SC3 since joining the Program? If you select “Yes,” please complete the remainder of this section. If you select “No,” skip to Part 3.

Yes

No

2.5.2 What was your company’s goal(s) in performing these outreach/communication efforts? (Check all that apply.)

Raise public awareness of SC3

Encourage organizations to join SC3

Raise awareness of the general need for chemical safety, management, and removals in schools

Other, please specify:      

2.5.3 Please describe your outreach/communication efforts (e.g., types of recipients and outreach methods) by completing Worksheet 5 at the end of this survey.

PART 3: SUCCESSES, BARRIERS AND FUTURE ACTIVITIES

3.1 Have your company’s objectives and expectations for joining the SC3 Program been realized to your satisfaction? If you select “No,” please briefly explain why not.

Yes

No

     

3.2 What is your most prohibitive barrier to removing chemicals from schools and/or implementing a responsible chemical management program? (Select one.) Please use the additional space below to elaborate on the barrier (e.g., root cause and ideas for overcoming it).

Expense

Liability

Resistance from schools

Other, please specify:      

     

3.3 What factors influence your company’s decision to continue in the Program? (Check all that apply.)

Your company’s ability to find and partner with new schools in need of support

Availability of resources in your company (e.g., money, personnel with relevant

expertise) to sustain your ongoing efforts

Continued involvement by EPA to address your needs and concerns

Other, please specify:      

3.4 What are your company’s plans under the SC3 Program over the coming years? (Check all that apply.)

Partnering with additional schools

Continuing to work with existing schools

Encouraging other companies to join in the future

Other, please specify:      

3.5 EPA is interested in collecting useful lessons that Partners have learned under SC3 and sharing them with others, e.g., at the SC3 Web site. If you have a success story that may be helpful to others, please describe it briefly (e.g., can you describe a situation in which you cleaned out a school's wastes and thereby avoided a potentially dangerous situation for students and/or faculty?).

     

3.6 EPA would like to collect best practices for conducting cleanouts or other activities under SC3 and share them with others, e.g., at the SC3 Web site. If you have identified or used any best practices that may be helpful to others, please describe them briefly.

     

3.7 EPA would like to identify ways to encourage other organizations to join SC3. We are interested in hearing your suggestions on methods that we should be using. Please describe them below.

     

3.8 How can EPA encourage existing Partners to continue their efforts under SC3? (Check all that apply.)

Hold an annual awards ceremony to recognize high achievers

Identify Partners (e.g., by company name) on SC3 Web site when they achieve specified milestones or distinctions during the year (e.g., for “most active” Partners)

Issue certificate, plaque, or other item of recognition when a Partner meets specified milestones or distinctions (e.g., performs a cleanout)

Help Partners find more schools to partner with

Help Partners overcome the barriers identified in Question 3.2

Other, please specify:      

3.9 Do you have any suggestions on how EPA can improve the resources available at the SC3 Web site? Please be as specific as possible.

     

Worksheet 1: Total Hours and Dollars Spent by Partner in Providing Services and Resources under SC3

Please complete Sections I through III of this worksheet.

I. Total Hours Spent by Your Company

Please estimate the number of hours that the employees of your company have spent collectively in providing services and resources under SC3 since joining the Program.

Hours Spent Providing SC3 Services and Resources

Less than 100 hours

101 to 200 hours

201 to 300 hours

301 to 400 hours

401 to 500 hours

Greater than 500 hours

(please estimate a range, e.g., "600 to 700 hours”):       hrs to       hrs

II. Total Expenditures of Your Company

Please estimate your company’s total expenditures in providing services and resources under SC3 since joining the Program. For each category of expenditure, please place an “X” in the table to indicate the range of your expenditure.

Categories of Expenditures
Expenditures for Materials/Supplies	Expenditures for Services (e.g., vendor, air travel)
Less than $1,000	Less than $1,000
$1,001-$5,000	$1,001-$5,000
$5,001-$10,000	$5,001-$10,000
$10,001-$15,000	$10,001-$15,000
$15,001-$20,000	$15,001-$20,000
Greater than $20,000 (please estimate a range, e.g.,“$25,000-$30,000”): $      to $     	Greater than $20,000 (please estimate a range, e.g.,“$25,000-$30,000”): $      to $     

3. Expenditures for Cleanouts

Please indicate the percentage of your expenditures estimated in Section II, above, that went towards chemical cleanouts. (Check only one box.) Note: The percentage that you provide below should be based on the total expenditures provided in the second column of the Table in Section II (see the column “Expenditures for Services”).

0% (i.e., you did not make any expenditures for cleanouts)

1-10%

11-20%

21-30%

31-40%

41-50%

Greater than 50%; please specify a range:      

Worksheet 2: Types and Quantities of Chemicals Inventoried at Schools

Since joining the SC3 Program, what types and quantities of chemicals has your company inventoried at schools? Please complete the table to answer this question to the best of your ability. If needed, you can use ranges (e.g., “10 to 15 gallons”) and similar methods to simplify your response.

Note 1: If you already have the requested information in an electronic format, you may e-mail it to EPA, along with your survey responses. You do not need to complete the table below.

Note 2: For “unknown” chemicals (i.e., chemicals whose identity is unknown), please complete one row of the table for all of them and summarize any information that is known.

Table of Chemicals Inventoried

Chemical or Trade Name of Substance Inventoried (see material safety data sheet, if necessary)	Location of Chemical Inventoried: (1) Science laboratory (2) Art classroom (3) Vocational shop (4) Maintenance area (5) Other (please specify)	Age of Substance Inventoried (if known)	Quantity or Volume of Chemicals Inventoried (specify units, e.g., pounds, grams, etc., if known)
     	     	     	     
     	     	     	     
     	     	     	     
     	     	     	     
     	     	     	     
     	     	     	     
     	     	     	     
     	     	     	     
     	     	     	     
     	     	     	     

Worksheet 3: Description of Training/Education

Please describe the training/education that you have supported at schools by completing the table below. We realize that a Partner may provide training/education to different types of recipients at a school across a range of training topics. Hence, the table below is designed for you to crosswalk specific training topics (in the left margin) to the types of recipients that may have received training/education in them (across the top margin). The shaded cells in the center of the table include a drop-down menu for you to indicate the frequency at which you trained/educated a specific type of recipient.

Please complete the table as follows:

1. Find the type(s) of recipient of your training/education in the top margin; then,

2. Find the topic(s) that you trained/educated that recipient(s) in (left margin); then,

3. Find their “shared” cell in the table (i.e., shaded cell) and use the pull down menu in it to indicate the frequency of this training/education.

For example, if you provide training to teachers in chemical safety each year, you would pull down the menu in the cell in the upper left-hand corner of the table and select “annually.”

Table on Training and Education

Training Topics	Types of Recipients of Training/Education
	Teachers	Maintenance/ building personnel	School administrators	Students	Other, please specify:     
Chemical safety
Emergency response
Regulatory compliance
Proper chemical management
Proper waste management
Other, please specify:      

Worksheet 4: Types and Quantities of Wastes Removed from Schools

Since joining the SC3 Program, what types and quantities of chemicals and other wastes has your company helped to remove from schools? You have two options for providing this information. Please complete Option 1 or Option 2.

Option 1: Refer to the table on the next page to learn the information we are requesting and see if you already have this information in an existing format (e.g., a paper copy of a hazardous waste manifest or shipping paper, an electronic file such as a MS Excel spreadsheet, etc.). If you do, you may submit this information instead of completing Option 2.

Option 2: Please complete the table on the next page by describing the chemicals and other wastes you have removed from schools since joining the Program. The table is designed to be as flexible as possible, as we realize that Partners will have varying levels of information about the wastes removed. At the bottom of this page, we provide some examples on how wastes can be summarized in the table.

Notes:

• In Waste Description column: describe the wastes removed. Be sure to mention chemical names and other descriptive information (e.g., solid, liquid or gas) if known. You may aggregate the following onto one row of the table 1) all “unknown wastes”; and 2) all lab packs (please specify one or a few of the predominant chemicals in the lab pack waste). See examples.

• In Quantity or Volume column: estimate the total quantity (weight) or volume of the waste and specify units. If you are uncertain of the quantity or volume, specify a range (e.g., “less than 10 pounds”).

• In Properties column: check all of the properties that you know of regarding the wastes. If needed, specify another property. See example.

Table of Wastes Removed (Example)

Waste Description	Quantity or Volume (specify units)	Properties (Check all that apply)
		Toxic, Poisonous, Generally Harmful	Ignitable/ Flammable	Acid or Base	Reactive/ Explosive	Other (please specify)	Not Harmful	Don’t Know
Approx 5 bottles of old cleaning detergent (liquid)	< 1 gal.					Irritant if in contact with skin
Unknown chemicals in various containers (liquids, solids)	20-30 lbs.					     
Approx 40 thermometers in boxes - liquid mercury	< 1 lb.					     
Misc classroom items in boxes – solids (e.g., chalk, erasers)	< 10 lbs.					     
Lab packs – liquids, solids (acetone, toluene, barium)	3 20-gallon lab packs					     

Table of Wastes Removed

Waste Description	Quantity or Volume (specify units)	Properties (Check all that apply)
		Toxic, Poisonous, Generally Harmful	Ignitable/ Flammable	Acid or Base	Reactive/ Explosive	Other (please specify)	Not Harmful	Don’t Know
     	     					     
     	     					     
     	     					     
     	     					     
     	     					     
     	     					     
     	     					     
     	     					     
     	     					     
     	     					     
     	     					     
     	     					     
     	     					     
     	     					     
     	     					     
     	     					     
     	     					     
     	     					     

Worksheet 5: Description of Outreach/Communication Related to SC3

Please complete the table below by describing your outreach/communication efforts related to SC3 since joining the Program. The table is designed for you to select the types of outreach/communication methods that you have used and to indicate the number and types of recipients of that outreach/communication.

Please complete the table as follows:

1. Find the type(s) of outreach/communication methods that you have used in regard to SC3 in the left hand column; then,

2. Select the approximate number of recipients who received that outreach/communication in the second column of the table (numbers are presented as ranges); then,

3. Select the type of recipient of that outreach/communication in the third column.

For example, if you made a presentation on SC3 at a conference and about 200 people attended, you would complete Row 3 of the table by selecting “151-200” in the second column and “Individuals” in the third. For some types of outreach in the table, a suggestion is provided on how to estimate the number of outreach recipients.

Number and Type of Outreach/Communication Recipients

Types of Outreach/Communication Related to SC3	Recipients
	Approximate Number of Recipients	Types of Recipients
1. Hand-outs and mailed items (e.g., fliers, brochures, etc.)
2. Emails and/or other electronic distribution methods used to inform recipients of SC3-related issues/topics
3. Conferences, seminars, teleconferences, etc. at which you discussed information related to SC3
4. Public service announcement(s)
5. Article(s) in a newsletter, journal, etc. (Note: You may estimate the number of “outreach recipients” based on the circulation of the newsletter or journal, if known)
6. Information on your Web site (Note: You may estimate the number of “outreach recipients” based on the number of “hits” at the Web page after the information was posted)
7. Other, please specify:      

PAPERWORK REDUCTION ACT BURDEN STATEMENT

The public reporting and recordkeeping burden for this collection of information is estimated to be one hour per response. Send comments on the Agency's need for this information, the accuracy of the provided burden estimates, and any suggested methods for minimizing respondent burden, including through the use of automated collection techniques to the Director, Collection Strategies Division, U.S. Environmental Protection Agency (2822T), 1200 Pennsylvania Ave., NW, Washington, D.C. 20460. Include the OMB control number in any correspondence. Do not send the completed survey to this address.

EPA Form No. 6200-05 September 5, 2008: Page 2