6700-022 Pre-Assessment of CHAs-in-Training

OMB Control Number: 2030-0051
CHA ID# _____________________________

Date _______________________

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.

Pre-Assessment of CHAs-in-Training
This assessment will help Public Health staff evaluate and improve the CHA
training program. We are not grading this.
Please answer the questions as well as you can. If you do not know an answer, it is
OK, please note “Don’t Know”. If you don’t understand any one question fully,
please move on to the next question and come back to it and ask us for
clarification.
Thank you for your feedback!

Knowledge
1. Which of these are true about the Duwamish River as a contaminated site
(Superfund Site)? (circle all that apply)
a. This site was contaminated by historical pollution from longtime ago.
b. The Environmental Protection Agency (EPA) determined that it is one of the
most polluted sites in the US to clean up.
c. The EPA pays for the cleanup.
d. The contamination at this site presents a risk to human health.
e. The cleanup site is 5 miles long.
f. Don’t know.

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Form Number: 6700-022

OMB Control Number: 2030-0051

2. What part of the Duwamish River has most of the harmful PCBs (manmade chemicals) and needs to be cleaned up by the EPA? (circle all that
apply)
a. Water of the river
b. Mud of the river
c. Plants in the river
d. Don’t know.
CHA ID# _____________________________

Date _______________________

3. How does chemical pollution get into the Duwamish River currently?
(Circle all that apply).
a. Storm water runoff
b. Combined sewer overflows (CSOs)
c. Erosion
d. Oil spills and leaks
e. Don’t know.

4. You cannot see the PCBs in the water, mud or in the seafood.
True

False

Don’t Know

5. Eating seafood with PCBs can make you feel sick right away.
True

False

Don’t Know

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Form Number: 6700-022

OMB Control Number: 2030-0051
CHA ID# _____________________________

Date _______________________

6. Please write the correct letter (A, B, C…) for the Agency next to their
Responsibility:
AGENCY
A. Public Health Seattle & King County
B. WA State Department of Health
C. US EPA
D. WA State Department of Ecology
E. WA State Department of Fish & Wildlife (WDFW)

RESPONSIBILITY
________ 1. Manages the cleanup of the mud in the Duwamish River Superfund
Site.
________ 2. Enforces fishing rules to protect the population of the fisheries.
________ 3. Responsible for controlling pollution sources from entering the
Duwamish River (e.g., storm water pollution). ________
________ 4. Leads this community program to promote healthy seafood
consumption on behalf of US EPA. __________
________ 5. Develops the Seafood Consumption Advisory.

Using the outreach materials in front of you, please answer the following
questions.

7. Can you name three health benefits of eating fish?
1._______________________________________________________
2._______________________________________________________
3._______________________________________________________
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Form Number: 6700-022

OMB Control Number: 2030-0051
CHA ID# _____________________________

Date _______________________

8. “Resident seafood” in the Duwamish River spend their entire lives in the
river so they are the most contaminated with PCBs. Please list three of the
resident seafood from the Duwamish River that Public Health Department
does not recommend people eating.
1._______________________________________________________
2._______________________________________________________
3._______________________________________________________

9. For fishers on the Duwamish River, which is the safest seafood to catch and
eat because it only spends a short time in the river and has lower PCBs?
(Circle all that apply)
a. English Sole
b. Salmon
c. Red Rock Crab
d. Clams
e. Don’t know

10.Which group(s) is most vulnerable to health effects from the PCBs in the
Duwamish resident seafood? (Circle all that apply)
a. Pregnant or nursing moms
b. Older person (65+)
c. Men and women who will not have kids
d. Babies and young children (0-5 years old)
e. Don’t know
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Form Number: 6700-022

OMB Control Number: 2030-0051
CHA ID# _____________________________

Date _______________________

11. Name three types of seafood from the supermarket that are a healthy
choice to eat 2-3 times per week:
1._______________________________________________________
2._______________________________________________________
3._______________________________________________________

12. If you were doing an outreach event about the Duwamish seafood
contamination:
a. What would be the activity?

b. Who would be your audience for this event?

c. What are the three most important messages you would want to convey
to that audience?

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Form Number: 6700-022

OMB Control Number: 2030-0051
CHA ID# _____________________________

Date _______________________

d. How would you describe the location of the Duwamish River to a
community member? (please provide a brief description).

Compass
Please rate your level of agreement with the following statement.
13.I feel confident that I can influence my community through this work.
Strongly
Agree

Agree

Neutral

Disagree

Strongly
Disagree

▪

▪

▪

▪

▪

Confidence and Skills
Please rate your level of agreement with the following statements.
14. I feel confident that I have the knowledge to conduct outreach in my
community.
Strongly
Agree
▪

Agree

Neutral

Disagree

▪

▪

▪

Strongly
Disagree
▪

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Form Number: 6700-022

OMB Control Number: 2030-0051
CHA ID# _____________________________

Date _______________________

15.I feel confident that I have the skills to conduct outreach in my community.
Strongly
Agree
▪

Agree

Neutral

Disagree

▪

▪

▪

Strongly
Disagree
▪

16.I feel like I can bring the voices of other community members back to
decision makers.
Strongly
Agree
▪

Agree

Neutral

Disagree

▪

▪

▪

Strongly
Disagree
▪

17.I have confidence that my (voice) ideas and recommendations are
considered and responded to by Public Health.
Strongly
Agree
▪

Agree

Neutral

Disagree

▪

▪

▪

Strongly
Disagree
▪

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Form Number: 6700-022

OMB Control Number: 2030-0051
CHA ID# _____________________________

Date _______________________

How confident are you in your ability to…
18.Present information to audiences in your own words.
Very
Confident
▪

Somewhat
Confident
▪

Neutral
▪

Not Very
Confident
▪

Not at All
Confident
▪

Not Very
Confident
▪

Not at All
Confident
▪

19.Organize an outreach activity.
Very
Confident
▪

Somewhat
Confident
▪

Neutral
▪

20.Facilitate a discussion and collect feedback from your community.
Very
Confident
▪

Somewhat
Confident
▪

Neutral
▪

Not Very
Confident
▪

Not at All
Confident
▪

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Form Number: 6700-022