Form 6700-021 CHA Behavior Survey

OMB Control Number: 2030-0051
This collection of information is approved by OMB under the Paperwork Reduction Act, 44 U.S.C. 3501 et seq. (OMB
Control No. 2030-0051). Responses to this collection of information are voluntary (40 CFR). 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 be 15-30 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 the
Regulatory Support Division Director, 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.

CHA Behavior Survey
The purpose of this survey to for us to gather background information about your general
fishing and seafood consumption practices. We will ask you to complete this survey every year.
There are no right or wrong answers. Your survey will be labeled with your ID number. You do
NOT need to write your name. Your responses will be kept confidential. We will summarize
information from these surveys in our program reports.
1. Please enter your ID number.

2. Which team are you with?

GAL Team

Khmer Team

Vietnamese Team

LARC Team

3. What year did you join the Community Health Advocate team?
Form Number: 6700-021

OMB Control Number: 2030-0051

Number must be between 2017 ~ 2024

4. Is there a fisher in your household?
Yes
No

5. If YES, where do they commonly go to fish?

6. How many times per year do you go fishing?
0
1-10
10-20
20-50
More than 50
7. What types of fish or shellfish do you catch from the Duwamish River?
Salmon
Crab
Perch
Other
Not applicable/I do not go fishing

8. What types of fish or shellfish do you receive and prepare from the Duwamish
River?
Salmon
Crab
Perch
Other
Not applicable/I do not receive seafood from the Duwamish River

Form Number: 6700-021

OMB Control Number: 2030-0051

9. How often do you share the fish or seafood you catch from the Duwamish River
with others?
Always
Very Often
Sometimes
Rarely
Never

10. How often does your household eat fish or shellfish caught by you or someone
you know? You can provide a general estimate.
More than 12 meals per month
7-12 meals per month
1-6 meals per month
Less than monthly
Never
11. Do you know how to fillet a fish?
Yes
No

12. What parts of the crab does your household commonly eat?
Crab meat (without guts)
Grab meat (with guts)
Not applicable – we don’t eat crab

13. Please enter today’s date

Form Number: 6700-021