6700-015 Moms and Caregivers Pledges

5 - Moms and Caregivers Pledges (Multiple Languages)
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.

1. Which language would you prefer complete your pledge?
?
¿en qué idioma prefiere completar su promesa?
Bạn muốn hoàn thành tờ đồng ý của mình bằng ngôn ngữ nào? Hãy chọn ngôn ngữ mình
muốn.
English
/ Khmer
Español / Spanish
Tiếng Việt / Vietnamese

Form Number: 6700-015

5 - Moms and Caregivers Pledges (Multiple Languages)
Moms and Caregivers Pledge (English)
OMB Control Number: 2030-0051
* 2. Participant ID:

* 3. What team are you with?

GAL Team

LARC Team

Khmer Team

Vietnamese Team

4. Moms and Caregivers Pledges
I commit to sharing the Duwamish advisory information and healthy alternative seafood choices with people
I know who fish or receive local catch.
I commit to accepting and eating only salmon from the Duwamish River from my friends and family.
I commit to preparing and eating only salmon from the Duwamish River or other alternative healthy
seafood options.

* 5. Date of commitment:

Today's date

Date

MM/DD/YYYY

Form Number: 6700-015

5 - Moms and Caregivers Pledges (Multiple Languages)
Moms and Caregivers Pledge (Khmer)
OMB Control Number: 2030-0051
* 6.
Participant ID:

* 7.

?

What team are you with?

GAL Team

Khmer Team

Vietnamese Team

8. Moms and Caregivers Pledge Khmer/English

I commit to sharing the Duwamish advisory information and healthy alternative seafood choices with people
I know who fish or receive local catch.

I commit to accepting and eating only salmon from the Duwamish River from my friends and family.

I commit to preparing and eating only salmon from the Duwamish River or other alternative healthy
seafood options.

* 9.
Date of commitment:

/ Today's date

Date

MM/DD/YYYY

Form Number: 6700-015

5 - Moms and Caregivers Pledges (Multiple Languages)
Moms and Caregivers Pledge (Spanish)
OMB Control Number: 2030-0051
* 10. #ID del participante:
Participant ID:

* 11. En que equipo estas?
What team are you with?

GAL Team

Khmer Team

Vietnamese Team

12. Moms and Caregivers Pledge Spanish/English
Me comprometo a compartir la información de Advertencias del Duwamish y de alternativas de mariscos
saludables con las personas que conozco que pescan o les regalan pesca local.
I commit to sharing the Duwamish advisory information and healthy alternative seafood choices with people
I know who fish or receive local catch.
Me comprometo a comer y aceptar de mis familiares y amigos solamente salmón del río Duwamish.
I commit to accepting and eating only salmon from the Duwamish River from my friends and family.
Me comprometo a preparar y comer solamente salmón del río Duwamish u otras opciones alternativas de
mariscos saludables.
I commit to preparing and eating only salmon from the Duwamish River or other alternative healthy
seafood options.

* 13. Fecha de compromiso:
Date of commitment:

Fecha / Date

Date

MM/DD/YYYY

Form Number: 6700-015

5 - Moms and Caregivers Pledges (Multiple Languages)
Moms and Caregivers Pledge (Vietnamese)
OMB Control Number: 2030-0051
* 14. số ID của quý vị:
PARTICIPANT ID #:

* 15. Bạn đang ở với đội nào?
What team are you with?

GAL Team

Khmer Team

Vietnamese Team

16. Moms and Caregivers Pledge Vietnamese/English
Tôi cam kết chia sẻ thông tin tư vấn của Duwamish và các lựa chọn hải sản thay thế lành mạnh với những
người tôi biết đánh cá hoặc đánh bắt tại địa phương.
I commit to sharing the Duwamish advisory information and healthy alternative seafood choices with people
I know who fish or receive local catch.
Tôi cam kết chỉ nhận và ăn cá hồi từ sông Duwamish từ bạn bè và gia đình của tôi.
I commit to accepting and eating only salmon from the Duwamish River from my friends and family.
I commit to preparing and eating only salmon from the Duwamish River or other alternative healthy
seafood options.
Tôi cam kết chỉ chế biến và ăn cá hồi từ sông Duwamish hoặc các loại hải sản lành mạnh khác.

* 17. Ngày cam kết:
Date of commitment:

Hôm nay là thứ
Today's date

Date

MM/DD/YYYY

Form Number: 6700-015