ATSDR Community Activities Survey - Hardcopy

ATSDR Communication Activities Survey (ACAS)

AttF1 Hardcopy ACAS 06122017 clean

Community Members - ACAS Hard Copy

OMB: 0923-0055

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Environmental Health and Your Community

Introduction

The Agency for Toxic Substances and Disease Registry (ATSDR) works with other federal agencies, states, and local governments to assess health risks in communities where people may come in contact with dangerous chemicals.

We use the best science to respond and provide health information to community members, environmental groups, tribal governments, and state, local, and other federal agencies to prevent or lower harmful health effects from dangerous chemicals.

ATSDR receives laboratory test results from things like soil, water, and air samples collected by federal, state and local partners, and let people know if there are health risks.



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Form Approved

OMB No. 0923-XXXX

Exp. Date MM/DD/YYYY

SURVEY ID |____|____|____|____|____|

Survey Instructions

The Program Evaluation Team in the Division of Community Health Investigations of the Agency for Toxic Substances and Disease Registry (ATSDR) is conducting a survey to gather feedback on how effective and timely ATSDR is in informing communities. The information will be used to help public health staff improve what they do in a way that’s best for community members.

We would like for you to complete the following survey.

As a token of appreciation, ATSDR will mail a $5 gift card to community members after completing this survey.

CONSENT: Providing your contact information and taking part in this survey is completely voluntary. You may skip any question or stop at any time. Your responses and identity will be kept private to the extent allowed by law. Digital data will be stored in secure computer files. We will not release your identity in any ATSDR reports. Please be sure to get all of your questions about the survey answered by ATSDR before you begin.

By proceeding, you indicate that you are 18 years of age or older, and CONSENT to participate in this survey.

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ATSDR estimates the average public reporting burden for this collection of information as 15 minutes per survey, including the time for reviewing instructions, searching existing data/information sources, gathering and maintaining the data/information 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 aspect of this collection of information, including suggestions for reducing this burden to CDC/ATSDR Information Collection Review Office, 1600 Clifton Road NE, MS D-74, Atlanta, Georgia 30333; ATTN: PRA (0923-xxxx).





  1. Before this public meeting, when did you first find out about the environmental risk(s) at (insert name of site here)__________________________________________________?

1 I didn’t know about it before this meeting

2 I don’t remember

3 Specify Month and Date or Approximate time of year (e.g., Summer 2015)____________________



  1. How did you first hear about the environmental risk(s) at this site?

Check ALL That Apply


1 Mailing (e.g., letter, report, flyer, sent to libraries, Health Departments, grocery stores, government facilities, county office, etc.)

2 Newspaper Advertisement

3 Email

4 TV/Radio (e.g., Public Service Announcement Ads)

5 Community Meeting

6 Official Government informational Meeting

7 Neighbor or Friend

8 I don’t remember

9 Other (e.g., social media, Twitter, Facebook, etc.) Specify:______________________________



  1. Do you live or work near the environmental site? Check ALL That Apply


1 I live near the environmental site

2 I work near the environmental site

3 I live AND work near the environmental site

4 I do not live OR work near the environmental site

Your Knowledge of Site Activities



  1. Do you know why ATSDR is at this site? Check ONE answer

1 Determine if there is a harmful environmental risk at this site

2 Clean up the environmental risk(s) at this site

3 Give medical treatment and healthcare services

4 Enforce laws and guidelines

5 Don’t know



  1. What do you know about the environmental risk(s) at this site now? Check ONE answer

1 It is an environmental risk but it does NOT pose a risk to human health

2 It is an environmental risk and it DOES pose a risk to human health

3 It was an environmental risk but it does NOT pose a risk to human health now

4 It was an environmental risk and it DOES still pose a risk to human health

5 None of the above



  1. Has ATSDR helped you to better understand the environmental risk(s) at this site?

1 Yes

2 No

3 Some, But Not All

4 Don’t know




  1. Do you know if you or your family have come in contact with environmental risk(s)?

1 Yes

2 No

3 Don’t know


  1. Before ATSDR (or your State or Local Agency) came to your community, did you know what you and your family should do to avoid contact with the environmental risk(s) at the site?

1 Yes

2 No

3 Don’t know



  1. Since ATSDR came into your community, do you NOW know more about what you and your family should do to avoid contact with the environmental risk(s) at the site?

1 Yes

2 No

3 Don’t know



  1. If you have questions, do you know who to contact in ATSDR (or in your State or Local Agency)?

1 Yes

2 No

3 Don’t know

Your Observations and Opinions about ATSDR

  1. Do you think ATSDR understands your health concerns related to the environmental risk(s) at this site?

1 Yes

2 No

3 Some, but not all

4 Don’t know



  1. Do you think ATSDR has given you all the information you need to address your health concerns related to the environmental risk(s) at this site?

1 Yes

2 No

3 Some, but not all

4 Don’t know



Your Observations and Opinions about Your Community

  1. After ATSDR’s work has finished, do you think your community will be better prepared to handle environmental risk(s) at this site?

1 Yes

2 No

3 Some, but not all

4 Don’t know

Self-evaluation Questions

  1. Since ATSDR came to your community, how do you NOW feel about your risk of exposure to environmental risk(s) at this site?

For each emotion, CHOOSE ONE answer to tell us how you feel right now.

EMOTION

I feel LESS of this emotion

I feel the SAME amount of this emotion

I feel MORE of this emotion

  1. STRESSED




  1. SATISFIED




  1. ANGRY




  1. CONTENTED




  1. WORRIED




  1. PLEASED




  1. FRUSTRATED




  1. AT EASE




  1. DISGUSTED




  1. HOPEFUL




  1. SCARED




About You


  1. How long have you lived at your current address? Check ONE Answer

1 Less than 1 month

2 At least 1 month but less than 1 year

3 At least 1 year but less than 5 years

4 At least 5 years or more


  1. How many children under 18 years old live with you? Check ONE Answer

1 None

2 1

3 2

4 3

5 4+



  1. What is the highest grade or level of school you completed? Check ONE Answer

1 8th grade or less

2 Some high school, but did not graduate

3 High school graduate or GED

4 Some college or 2-year degree

5 4-year college graduate

6 More than a 4-year college degree

7 None of the Above





  1. Do you consider yourself to be Hispanic or Latino?

1 Hispanic or Latino

2 Not Hispanic or Latino



  1. What race or races do you consider yourself to be? Check ALL that Apply

1 American Indian or Alaskan Native

2 Asian

3 Black or African American

4 Native Hawaiian or Other Pacific Islander

5 White



  1. How old are you? Check ONE Answer

1 18 to 24

2 25 to 34

3 35 to 44

4 45 to 54

5 55 to 64

6 65 to 74

7 75 or older



  1. Are you male or female? Check ONE Answer

1 Male

2 Female

Response to the Survey



  1. Do you have any concerns about anything else related to possible environmental risk(s) in your community that the survey did not ask?

1 Yes

2 No

If Yes, specify concerns:___________________________________________________________________________________

__________________________________________________________________________________________________________________________________________________________________________________________________________________



  1. Do you have any other feedback?

1 Yes

2 No

If Yes, specify feedback:___________________________________________________________________________________

__________________________________________________________________________________________________________________________________________________________________________________________________________________



Last updated June 12, 2017 / 12 /



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