Attachment A: Data collection instrument- Word
Form approved
OMB No. 0920-0879
Expiration date: 04/30/2017
Data Collection Regarding Private Well Owner Outreach Programs
This is a voluntary data collection aimed at gathering current information about public health programs geared toward private well owners. The data collection is designed for environmental health staff at state, local, and tribal environmental health and agricultural departments who are government employees and who conduct outreach to private well owners.
This data collection was developed by a team of University of Illinois researchers who created a training program titled, “Private Well Class.” Our team would like to invite you to participate in this data collection to help us learn from other comparable programs. Based on what we learn, we hope to boost well owner participation in our program and also to share our finding with other public health practitioners who could use the information to improve their outreach programs. A final report on this project will be made publicly available. All identifiable information will remain anonymous and all data kept secure.
This is a web-based data collection that is estimated to average 18 minutes per response. You can leave the website and come back later using the same URL. However once you click on “submit” after the last question, your answers are locked and you will not be able to edit or add information. If you realize you have more to add, contact us and we will work with you to make that happen.
Thank you for participating.
Contact Information:
Steve Wilson,
Principal Investigator
[email protected]
217-333-0956
Private Well Owner Program Information
What was the name of your private well owner program?
_________________________________________________________________________
Your private well owner program was designed to serve well owners at what scale?
O local
O community
O county
O multi-county
O state
O multi-state
O national
What was the source of funding? (Please assign a percentage to each that apply, if there were multiple funding sources for your program)
local ________%
county _________%
state ________%
national/ federal ________%
What was the type of funding? (Please assign a percentage to each that apply, if there were multiple funding sources for your program)
internal (regular budget item) ________%
grant _________%
state appropriation _________%
contract _________%
How much funding was dedicated to your private well owner program?
O less than $1,000
O $1,000 to $5,000
O $5,000 to $20,000
O $20,000 to $50,000
O over $50,000
What was your private well owner program duration? (just the last instance if repeated)
O ongoing (part of regular business practices)
O less than a month (e.g., during NGWA’s Groundwater Awareness week)
O between a month and a year
O more than a year
How many well owners participated in your private well program?
___________
Was your private well owner program limited to a specific number of well owners?
O No
O Yes
[If no, go to 9]
[If yes, go to 10a]
How many well owners could have participated? (e.g., number of wells in study area, area rural population, etc.) (ie, maximum total possible participants)
______________
[skip to 11]
(a) Why were the number of well owners limited for your program?
__________________________________________________________________________
__________________________________________________________________________
__________________________________________________________________________
(b) Were the well owners in your private well owner program selected to participate or were they included, first come, first served?
O Well owners were selected by program staff
O Well owners were included first come, first served
[if selected, skip to 11]
[if first come, first served, go to 10c]
(c) How many potential participants were turned away because of limitations?
_______________
(d) How many potential well owners could have participated? (e.g., number of wells in study area, area rural population, etc.) (ie, maximum total possible participants)
______________
[end of skip questions for #10]
Did participants in your program provide feedback?
O Yes, and I have that information
O Yes, but I do not have that information
O No
How many staff were involved in the program? ________________________________
Was anyone specifically in charge of outreach?
O Yes
O No
Was there a report or final product? (final product could be an updated website, a rule change, warning letter to well owners, etc)
O Yes, and I have that information
O Yes, but I do not have that information
O No
Level of Engagement.
Please describe any quantitative measures of program completion (e.g., test scores, etc.), engagement with the program (e.g., actions well owner completed as a result of your program, etc.), or interaction between the program and participants (e.g., requests for information/follow up, etc.) _________________________________________________________________
_______________________________________________________________________
_______________________________________________________________________
_______________________________________________________________________
_______________________________________________________________________
Program Factors
(random order for each participant, except “other” is always last)
Please indicate who partnered with you to complete your private well owner program. (include all that apply and list organization name)
Government ___________________________________________________________
University/school _______________________________________________________
Business ______________________________________________________________
Civic _________________________________________________________________
Environmental _________________________________________________________
Agricultural ____________________________________________________________
Landowner ____________________________________________________________
Other ________________________________________________________________
_______________________________________________________________________
(random order for each participant, except “other” is always last)
What methods were used to advertise your private well owner program? (check all that apply)
O Website
O E-mail
O Radio
O Newspaper
O Press release
O Flyers
O Word-of-mouth
O Public Meetings
O Other _________________________________________________________________
________________________________________________________________________
Were there any factors that may have influenced participation?
(check all that apply)
O Concern over a local issue
O Incentive given to well owner
O Regulatory
O Other (Please describe)
________________________________________________________________________
________________________________________________________________________
(if they check “concern over a local issue”, go to 18b, else skip to 19)
(b). Please describe the local issue that may have influenced participation in your program?
_________________________________________________________________________
_________________________________________________________________________
_________________________________________________________________________
(random order for each participant, except “other” is always last)
If there were any program incentives, what were they?
(check all that apply)
O Free Testing
O Additional financial Incentive
O Educational Credit
O Gift
O Free or reduced professional service
O Other _________________________________________________________________
________________________________________________________________________
(random order for each participant, except “other” is always last)
What format or formats were used to implement your private well owner program? (check all that apply)
O Website (e.g., online learning or testing, webinars, etc.)
O E-mail (e.g., direct email, newsletter, etc.)
O Classroom based (face-to-face)
O Well Testing Program (e.g., providing bottles, portable test kits, sample analysis, etc.)
O Train-the-trainer (e.g. Coop Extension Master Well Owner Program, etc.)
O Direct Services
O Other _________________________________________________________________
________________________________________________________________________
(random order for each participant, except “other” is always last)
What additional activities did participants engage in as part of your private well owner program?
(check all that apply)
O Collecting samples
O Attending a meeting
O Submitting questions/requesting information
O Hands-on participation with private well related activities
O Other _________________________________________________________________
________________________________________________________________________
The results of this survey will be evaluated to provide helpful guidance and suggested best approaches to outreach in support of future well owner outreach and sampling programs. We would like to include an appendix in the report that lists your responses to these questions. Do we have your permission to list this information?
O Yes
O No
O Yes, but please don’t list the answers to these questions: ___, ____, ____, ____, ____, ____, ____, ____, ____, ____, ____, ____, ____, ____, ____, ____, ____, ____, ____, ____, ____, ____
Attitudes and Reaction to Program
Was your private well owner program successful?
O 1. Unsuccessful
O 2. Not Very Successful
O 3. Successful
O 4. Very Successful
O 5. Extremely Successful
[If 1 or 2, go to 24a]
[If 3, 4, or 5, go to 24b]
(a) Why wasn’t your private well owner program successful?
_______________________________________________________________________
_______________________________________________________________________
[skip to 25]
(b) Why was your private well owner program successful?
________________________________________________________________________
________________________________________________________________________
Based on your experiences with these types of programs, how would you now go about motivating well owners to participate?
_______________________________________________________________________
_______________________________________________________________________
Thank you for taking the time to complete this survey.
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Public reporting burden of this collection of information is estimated to average 18 minutes per response, including the time for reviewing the instructions, searching existing data sources, gathering and maintaining the data needed, and completing and reviewing the collection of information. An agency may not conduct or sponsor, and a person is not required to respond to a collection of information unless it displays a currently valid OMB control number. Send comments regarding this burden estimate or any other aspects of this collection of information, including suggestions for reducing this burden to CDC/ATSDR Information Collection Review Office, 1600 Clifton Rd, NE, MS D-74, Atlanta, GA 30333; ATTN: PRA (0920-0879).
| File Type | application/vnd.openxmlformats-officedocument.wordprocessingml.document |
| Author | Allison Tepper |
| File Modified | 0000-00-00 |
| File Created | 2021-01-28 |