Form 5800-091 EJ TCTAC Intake Form Center A

OMB Control Number: 2030-0051

Expiration Date: 05/31/2024

EJ TCTAC Intake Form Center A

This collection of information is approved by OMB under the Paperwork Reduction Act, 44 U.S.C. 3501 et seq. OMB Control Number: 2030-0051. Responses to this collection of information are voluntary. 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. The public reporting and recordkeeping burden for this collection of information is estimated to 15 minutes 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 to Director, Information Engagement Division; U.S. Environmental Protection Agency (2821T); 1200 Pennsylvania Ave., NW; Washington, D.C. 20460.  Include the OMB control number in any correspondence. Do not send the completed form to this address.

Required: The collection of information required for the rendering of appropriate services deployed by Center A.

Your information

• Your first name

• Your last name

• Your title

• Your organization/business name or community affiliation (write N/A

• if not applicable) [Response is Required]

• Website of your organization/business (if applicable)

• Which of the following best describes your business/organization?(Select

• all that apply) [Response is Required]

  • Community based or grassroots organization

  • Nonprofit organization

  • Philanthropic

  • Tribal Government or Intertribal Consortia

  • Native American Organization (includes nonprofits, cooperatives, corporations, partnerships)

  • Local Governments (as defined by 2 CFR 200.1 – includes cities, towns, municipalities,

  • and counties, public housing authorities and councils of government)

  • Institutions of higher education (e.g., private and public universities and colleges,

  • including community colleges)

  • Private business 

  • Special district

  • Don't know/Not sure

  • Other (please specify)

• Preferred form of contact

• [Response is Required]

  • Email 

  • Phone call

  • SMS/text messaging

If previous response = Email 

• Please provide your E-mail address for future communications

• [Open ended]

• What is your preferred language for future communications?

• [Open ended]

If previous response = phone call or SMS

• Please provide your phone number for future communications

• [Open ended]

• What is your preferred language for future communications?

• [Open ended]

Community information

Please provide the following socio-demographic information for the impacted community or communities for which you are seeking technical assistance.

• Name of the community [Open ended]

• Which state is this community located in? (Select all that apply) [Response is Required]

  • Alaska

  • Idaho

  • Oregon

  • Washington

  • Other (please specify)  

• Please select the group(s) that represent the impacted community or communities. (Select all that apply) [Response is Required]

  • Asian 

  • Black or African American

  • Elder persons (i.e., 65 years and older)

  • Hispanic or Latino/Latina/Latinx

  • Houseless persons

  • Immigrants

  • Lesbian, gay, bisexual, transgender, and queer (LGBTQ+) persons

  • Low income persons

  • Middle Eastern or North African

  • Mesoamerican Indigenous

  • Native Hawaiian and Pacific Islanders

  • Native American/Indigenous/American Indian/Alaska Native

  • Persons who live in rural or remote areas

  • Persons with disabilities

  • Refugees 

  • Religious minorities

  • Other, please specify

(The information will be gathered to understand the reach of the program to priority communities. )

• Please use this space if you would like to provide more details about

• the group(s) that represent the impacted community or communities. (e.g., Thai community in Eastern Oregon).[Open

• ended]

• What is the approximate population of the impacted community?

• [Response is Required]

  • 2,500 or under

  • 2,500 to 10,000

  • 10,000 to 50,000

  • More than 50,000

  • I am not sure

• What is the preferred communication language of the impacted community?

• [Open ended]

Environmental or Energy Justice Issue

• Please provide a brief description (500 words or less) of the energy or environmental

• justice issue faced by the impacted community or communities. [Open

• ended] [Response is Required]

• How can we help you? In 500 words or less, please describe the assistance you’re looking

• for. If you’re not sure, that’s ok, we will follow up with you to  discuss further.

• [Open ended] [Response is Required]

• In 500 words or less, please share what is the desired community outcome for this request?

• If you’re not sure, that’s ok, we will follow up with you to  discuss further.

• [Open ended] [Response is Required]

Final section

How did you hear about the Northwest Environmental Justice Center? [Open ended] [Response is Required]

EPA Form: 5800-091