6700-023 Post-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.

Post-Assessment of CHAs-in-Training
Please answer the questions as well as you can. If you do not know an answer, it is
OK to write “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.

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.
2. What part of the Duwamish River has most of the harmful PCBs (man-made
chemicals) and needs to be cleaned up by the EPA? (circle one answer)
a. Water of the river
b. Mud of the river
c. Plants in the river
d. Don’t know
1
Form Number: 6700-023

OMB Control Number: 2030-0051

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
CHA ID# _____________________________

Date _______________________

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

2
Form Number: 6700-023

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 appropriate outreach materials, please answer the following questions.
7. Can you name three health benefits of eating fish?
1._______________________________________________________
2._______________________________________________________
3._______________________________________________________

3
Form Number: 6700-023

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 one answer)
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
4
Form Number: 6700-023

OMB Control Number: 2030-0051
CHA ID# _____________________________

Date _______________________

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

1.____________________________________________
2.____________________________________________
3.____________________________________________

** Which of the following are ways that you can be an informed customer of
seafood at supermarkets? [Choose all that apply]
a.
b.
c.
d.
e.

Call the Health Department hotline
Ask the vendor where it came from
Look for the country of origin on the label
Use the supermarket safety guide
Always buy the most expensive option

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?
5
Form Number: 6700-023

OMB Control Number: 2030-0051
CHA ID# _____________________________

Date _______________________

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

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

13.Please explain this picture in 1-2 sentences.

6
Form Number: 6700-023

OMB Control Number: 2030-0051

CHA ID# _____________________________

Date _______________________

14.Explain why PCBs are most harmful to babies and young children.

7
Form Number: 6700-023

OMB Control Number: 2030-0051
CHA ID# _____________________________

Date _______________________

Compass
Please rate your level of agreement with the following statement.
15.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.
16. I feel confident that I have the knowledge to conduct outreach in my
community.
Strongly
Agree
▪

Agree

Neutral

Disagree

▪

▪

▪

Strongly
Disagree
▪

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

Agree

Neutral

Disagree

▪

▪

▪

Strongly
Disagree
▪

8
Form Number: 6700-023

OMB Control Number: 2030-0051

CHA ID# _____________________________

Date _______________________

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

Agree

Neutral

Disagree

▪

▪

▪

Strongly
Disagree
▪

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

Agree

Neutral

Disagree

▪

▪

▪

Strongly
Disagree
▪

How confident are you in your ability to…
20. 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
▪

21. Organize an outreach activity.
Very
Confident
▪

Somewhat
Confident
▪

Neutral
▪

9
Form Number: 6700-023

OMB Control Number: 2030-0051

CHA ID# _____________________________

Date _______________________

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

Somewhat
Confident
▪

Neutral
▪

Not Very
Confident
▪

Not at All
Confident
▪

10
Form Number: 6700-023

OMB Control Number: 2030-0051
CHA ID# _____________________________

Date _______________________

Empowerment
Please answer the questions related to your team’s definition of community
empowerment.

11
Form Number: 6700-023

OMB Control Number: 2030-0051
CHA ID# _____________________________

Date _______________________

GAL Team
Juntar a la comunidad para crear conocimiento y transmitir información y
herramientas para tomar acción para lograr un objetivo en común.
Community Empowerment: Gather the community together to create awareness,
transmit information, knowledge, and tools to take action to obtain an objective in
common.

a. How empowered do you feel to gather the community together to create
awareness, transmit information, knowledge, and tools to take action to
obtain an objective in common?
Very
Empowered
▪

Somewhat
Empowered
▪

Neutral
▪

Not Very
Empowered
▪

Not at All
Empowered
▪

b. How empowered did you feel before this training with Public Health?
Very
Empowered
▪

Somewhat
Empowered
▪

Neutral
▪

Not Very
Empowered
▪

Not at All
Empowered
▪

c. Did your feelings of empowerment change? Why or why not?

12
Form Number: 6700-023

OMB Control Number: 2030-0051
CHA ID# _____________________________

Date _______________________

Vietnamese Team
một nhóm người có cùng ý kiến để tạo nên sức mạnh đoàn kết, bảo vệ quyền lợi về
cuộc sống của họ.
Community Empowerment: The capacity of a group of people to have a common
idea to build common strength and collaboration to protect the rights and benefits in
their lives.

a. How empowered do you feel to unite people to build common strength and
collaboration to protect the rights and benefits in their lives?
Very
Empowered
▪

Somewhat
Empowered
▪

Neutral
▪

Not Very
Empowered
▪

Not at All
Empowered
▪

d. How empowered did you feel before this training with Public Health?
Very
Empowered
▪

Somewhat
Empowered
▪

Neutral
▪

Not Very
Empowered
▪

Not at All
Empowered
▪

e. Did your feelings of empowerment change? Why or why not?

13
Form Number: 6700-023

OMB Control Number: 2030-0051
CHA ID# _____________________________

Date _______________________

Cambodian Team

“បង្កើនអំណាចសហគមន៍”:

ប្បមួលផ្តំសមាជិកសហគមន៍បង្កើតសំងល្តតមួយងែើមបីងប្ោកឈរប្បឆំ្និ្ភាពអយុតិធម៌ទទឹមគ្នាង ោះតែរងយើ្ក៏ប្តូវសហោរជាមួយនិ្រដ្ឋាភិបាលកាត្ ោរតសែ្រ
កយុតិធម៌ឬចងមលើយ
Community Empowerment: Bring our community together, to create one strong
voice, and fight for our right and stand up to injustice. We must work with the
government and other organizations to find the solution.

a. How empowered do you feel to bring your community and organizations
together to create one strong voice and fight for our right and stand up to
injustice?
Very
Empowered
▪

Somewhat
Empowered
▪

Neutral
▪

Not Very
Empowered
▪

Not at All
Empowered
▪

b. How empowered did you feel before this training with Public Health?
Very
Empowered
▪

Somewhat
Empowered
▪

Neutral
▪

Not Very
Empowered
▪

Not at All
Empowered
▪

c. Did your feelings of empowerment change? Why or why not?

14
Form Number: 6700-023