Community Environmental Concerns Survey

0703-EGEN exp. XX/XX/XXXX

OMB CONTROL NUMBER: XXXX-XXXX

OMB EXPIRATION DATE: XX/XX/XXXX

[insert location] COMMUNITY ENVIRONMENTAL CONCERNS SURVEY -

[Introduction]

AGENCY DISCLOSURE NOTICE

The public reporting burden for this collection of information, 0703-EGEN, is estimated to average 20 minutes per response, including the time for reviewing instructions, searching existing data sources, gathering, and maintaining the data needed, and completing and reviewing the collection of information. Send comments regarding the burden estimate or burden reduction suggestions to the Department of Defense, Washington Headquarters Services, at [email protected]. Respondents should be aware that notwithstanding any other provision of law, no person shall be subject to any penalty for failing to comply with a collection of information if it does not display a currently valid OMB control number.

Thank you for taking time to complete the Environmental Concerns for [insert site]. This survey is anonymous and voluntary. This 15-question survey may take approximately 20 minutes, depending on your level of participation, and will be used to develop a Community Involvement Plan (CIP). This is also a free comment option at the end of this survey. Your responses are invaluable as they help the Navy understand how best to keep your community informed and involved on this issue, and how you prefer to receive information. Please be careful not to include any personal identifying information within this survey. If you have any questions about this survey, please contact [insert email].

SECTION 1 - GENERAL:

Q1 Are you a resident of [insert location] or the surrounding area? ___No __ Yes. [if select yes go to Q1b]

Q1b. How long have you been a resident? ___ Years ____ month’s ___ Weeks. What is your zip code? ________

Q2 How far do you live from the former Navy [insert location or previous base name]?

__ Within 2 miles __ between 2 and 5 miles __ between 5 and10 miles ___ between 10 and15 miles __ More than 20 miles

Q3 How would you describe your current affiliation with the former Navy [insert location or previous base name]? ___ Former Navy employee ___ Former Grumman employee ___ Local Resident ___ Business Owner ___ Military/Former Military ___ Public/Elected Official
___ Civic Group/Homeowner Assoc.___ Environmental Group ___ Restoration Advisory Board (RAB) member ___ other (Please describe)

SECTION 2 - ENVIRONMENTAL:

Q4 Based on the above former site, how important is each environmental issue?

QUALITY OF	extremely	very	moderately	slightly	Not at all	unaware
SURFACE WATER
GROUND WATER
DRINKING WATER
SOIL
SOIL VAPOR

Q5 (Based on #4) are there specific chemicals that concern you? [if select yes go to Q5b]

__ Yes. What concerns you most about the above chemical(s)? (Health, property value etc.)

__ No

__ Not sure/I am not aware of specific chemicals

Q5b If yes what concerns, you most about these chemicals? (Open end item)

Q6 Prior to taking this survey were you aware the Navy has established an Environmental Restoration program to identify, investigate, and clean up former waste disposal sites on military property? __ Yes __ No

Q7 Prior to taking this survey, were you aware the Department of Defense has established Restoration Advisory Boards (RABs) across the country that consists of community members who help address environmental restoration, at military installations and former installations, within their respective community and share their knowledge of the restoration being performed by the DOD with the broader local community? __ Yes, I am aware of RABS and have attended a RAB meeting ___ Yes, I am aware of RABs but have never attended a RAB meeting __ No, I am not aware of RABs

Q8 [if select I am interested in learning more … go to Q8b] Which statement best describes your interest in the RAB supporting [insert location of previous base name]? __ I am interested in learning more about the RAB __ I am interested in learning more how I can serve on the RAB __ I am not interested in learning more about or serving on the RAB

Q8b If you would like to learn more about the RAB, please contact: [insert email or contact information] If you would like to serve on the RAB please go to [enter WEBSITE] and fill out the application and return to [enter email].

SECTION 3 - INFORMATION/COMMUNICATION:

Q9 Please rate your confidence in the Navy to address environmental issues at [insert name of site] __ Not confident at all __ slightly confident __ somewhat confident __ fairly confident __ completely confident

Q10 Please rate your confidence in the Navy to keep you fully informed about the state of the environment issues at [inset location]. __ Not confident at all __ slightly confident __ somewhat confident __ fairly confident __ completely confident

Q11 How are you currently informed about the Navy’s efforts to address environmental issues at [insert location]? __ I am not kept informed __ RAB members __ I go to the Navy website __ news media __ social media

Q12 How would you prefer to be kept informed about the Navy’s efforts to address environmental issues at [insert location] __ RAB members __ I go to the Navy website __ news media __ social media __ I am not interested in being kept informed about this

Q13 [if select yes go to Q13b] Have you visited the Navy’s website for [insert location] available at [insert website] __ No __Yes.

Q13b Please provide feedback you may have regarding [insert website]. (Open end item)

SECTION 4 - CLOSING:

Q14 If you know anyone who would like to learn more about the Navy’s cleanup efforts or the related Restoration Advisory Board, please have them contact: [insert email or contact information]

Q15 Please provide any other comments, concerns, or suggestions. Please do not provide any personally identifying information in your response. (Open end item)

[Closing]

Thank you for completing the Navy’s Environmental Concerns for [insert site]. Your responses will help the Navy develop a Community Involvement Plan (CIP) that will be available on the Navy’s website for download later this year. Your responses will also help the Navy understand how best to keep your community informed and involved. If you said you would be interested in learning more or participating on the RAB, someone will be contacting you shortly. If you would like to learn more about the site or opportunities go to [enter WEBSITE].