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pdf4 - Moms and Caregivers Self-Assessment (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 to take this survey in?
?
¿en qué idioma prefiere tomar esta encuesta?
Bạn muốn hoàn thành bảng khảo sát của mình bằng ngôn ngữ nào? Hãy chọn ngôn ngữ mình
muốn.
English
/ Khmer
Español / Spanish
Tiếng Việt / Vietnamese
Form Number: 6700-014
4 - Moms and Caregivers Self-Assessment (Multiple Languages)
Moms and Caregivers Self-Assessment Survey (English)
OMB Control Number: 2030-0051
Expiration Date: 05/31/2024
* 2. Participant ID:
* 3. Which team are you with?
GAL Team
Khmer Team
LARC Team
For the next questions, please use the following scale:
Vietnamese Team
4. BEFORE the workshop, how would you rate your level of knowledge about the pollution in
the Duwamish River?
None
Low
Moderate
High
5. Now, AFTER the workshop, how would you rate your level of knowledge about the pollution
in the Duwamish River?
None
High
Low
Moderate
6. BEFORE the workshop, how would you rate your level of knowledge about the health
information related to the Duwamish Seafood Consumption Advisory?
None
Low
Moderate
High
7. Now, AFTER the workshop, how would you rate your level of knowledge about the health
information related to the Duwamish Seafood Consumption Advisory?
None
High
Low
Moderate
8. BEFORE the workshop, How would you rate your level of confidence to decline resident
seafood caught in the Duwamish River from your family and neighbors?
None
Low
Moderate
High
9. Now, AFTER the workshop, how would you rate your level of confidence to decline resident
seafood caught in the Duwamish River from your family and neighbors?
None
High
Low
Moderate
10. BEFORE the workshop, how would you rate your level of confidence to prepare a skinless
healthier salmon meal from the Duwamish River?
None
Low
Moderate
High
11. Now, AFTER the workshop, how would you rate your level of confidence to prepare a
skinless healthier salmon meal from the Duwamish River?
None
High
Low
Moderate
* 12. Please enter today's date
Date / Time
Date
MM/DD/YYYY
Form Number: 6700-014
4 - Moms and Caregivers Self-Assessment (Multiple Languages)
Moms and Caregivers Self-Assessment POST-Survey (Khmer)
OMB Control Number: 2030-0051
* 13.
Participant ID:
* 14.
?
Which team are you with?
GAL Team
Khmer Team
Vietnamese Team
15.
?
BEFORE the workshop, how would you rate your level of knowledge about the pollution in the
Duwamish River?
/ None
/ Low
/ Moderate
/ High
16.
?
AFTER the workshop, how would you rate your level of knowledge about the pollution in the
Duwamish River?
/ None
/ High
/ Low
/ Moderate
17.
?
BEFORE the workshop, how would you rate your level of knowledge about the health
information related to the Duwamish Seafood Consumption Advisory?
/ None
/ Low
/ Moderate
/ High
18.
?
AFTER the workshop, how would you rate your level of knowledge about the health
information related to the Duwamish Seafood Consumption Advisory?
/None
/ High
/ Low
/ Moderate
19.
?
BEFORE the workshop, how would you rate your level of confidence to avoid resident seafood
caught in the Duwamish River if someone offers it to you?
/None
/ Low
/ Moderate
/ High
20.
?
AFTER the workshop, how would you rate your level of confidence to avoid resident seafood
caught in the Duwamish River if someone offers it to you?
/ None
/ High
/Low
/ Moderate
21.
?
BEFORE the workshop, how would you rate your level of confidence to prepare a skinless
healthier salmon meal from the Duwamish River?
/ None
/Low
/ Moderate
/High
22.
?
AFTER the workshop, how would you rate your level of confidence to prepare a skinless
healthier salmon meal from the Duwamish River?
/ None
/ High
/ Low
/ Moderate
* 23.
Today's date:
/ Date
Date
MM/DD/YYYY
Form Number: 6700-014
4 - Moms and Caregivers Self-Assessment (Multiple Languages)
Moms and Caregivers Self-Assessment POST-Survey (Spanish)
OMB Control Number: 2030-0051
* 24. #ID del participante:
Participant ID:
* 25. Which team are you with?
En que equipo estas?
GAL Team
Khmer Team
Para la siguiente pregunta, use la siguiente escala:
Vietnamese Team
26. ANTES del taller, póngale un índice a su conocimiento de la contaminación del rio
Duwamish
BEFORE the workshop, how would you rate your level of knowledge about the pollution in the
Duwamish River?
ninguno / None
bajo / Low
mediando /Moderate
alto / High
27. DESPUES del taller, póngale un índice a su conocimiento de la contaminación del rio
Duwamish
Now AFTER the workshop, how would you rate your level of knowledge about the pollution in
the Duwamish River?
ninguno / None
alto / High
bajo / Low
mediando / Moderate
28. ANTES del taller, como calificaría su nivel de conocimiento sobre la información de salud
relacionada a las Advertencias de Consumo de Mariscos del Duwamish?
BEFORE the workshop, how would you rate your level of knowledge about the health
information related to the Duwamish Seafood Consumption Advisory?
ninguno /None
bajo / Low
mediando / Moderate
alto / High
29. DESPUES del taller, como calificaría su nivel de conocimiento sobre la información de
salud relacionada a las Advertencias de Consumo de Mariscos del Duwamish?
Now AFTER the workshop, how would you rate your level of knowledge about the health
information related to the Duwamish Seafood Consumption Advisory?
ninguno / None
alto / High
bajo / Low
mediando / Moderate
30. ANTES del taller, como calificaría su nivel de confianza para rechazar el pescado y
mariscos residentes capturados en el río Duwamish si alguien se lo ofrece?
BEFORE the workshop, how would you rate your level of confidence to avoid resident seafood
caught in the Duwamish River if someone offers it to you?
ninguno / None
bajo / Low
mediando / Moderate
alto / High
31. DESPUES del taller, como calificaría su nivel de confianza para rechazar el pescado y
mariscos residentes capturados en el río Duwamish si alguien se lo ofrece?
Now AFTER you attended the workshop, how would you rate your level of confidence to avoid
resident seafood caught in the Duwamish River if someone offers it to you?
ninguno / None
alto / High
bajo / Low
mediando / Moderate
32. ANTES del taller, cómo calificaría su nivel de confianza para preparar una comida más
saludable de salmón sin piel del río Duwamish?
BEFORE the workshop, how would you rate your level of confidence to prepare a skinless
healthier salmon meal from the Duwamish River?
ninguno / None
bajo / Low
mediando / Moderate
alto / High
33. DESPUES del taller, cómo calificaría su nivel de confianza para preparar una comida más
saludable de salmón sin piel del río Duwamish?
Now, AFTER the workshop, how would you rate your level of confidence to prepare a skinless
healthier salmon meal from the Duwamish River?
ninguno / None
alto / High
bajo / Low
mediando / Moderate
* 34. Today's date
Fecha
Fecha / Date
Date
MM/DD/YYYY
Form Number: 6700-014
4 - Moms and Caregivers Self-Assessment (Multiple Languages)
Moms and Caregivers Self-Assessment POST-Survey (Vietnamese)
OMB Control Number: 2030-0051
* 35. số ID của quý vị
PARTICIPANT ID #
* 36. Bạn đang ở với đội nào?
Which team are you with?
GAL Team
Khmer Team
Đối với các câu hỏi tiếp theo, vui lòng sử dụng thang điểm sau
Vietnamese Team
37. TRƯỚC hội thảo, bạn đánh giá mức độ hiểu biết của mình về tình trạng ô nhiễm ở sông
Duwamish như thế nào?
BEFORE the workshop, how would you rate your level of knowledge about the pollution in the
Duwamish River?
Không / None
Thấp / Low
Trung Bình / Moderate
Cao / High
38. Bây giờ, SAU hội thảo, bạn đánh giá mức độ hiểu biết của mình về tình trạng ô nhiễm ở
sông Duwamish như thế nào?
Now AFTER the workshop, how would you rate your level of knowledge about the pollution in
the Duwamish River?
Không / None
Cao / High
Thấp / Low
Trung Bình / Moderate
39. TRƯỚC hội thảo, quý vị đánh giá mức độ hiểu biết của mình như thế nào về thông tin sức
khỏe liên quan đến Lời khuyên Tiêu thụ Hải sản Duwamish?
BEFORE the workshop, how would you rate your level of knowledge about the health
information related to the Duwamish Seafood Consumption Advisory?
Không / None
Thấp / Low
Trung Bình / Moderate
Cao / High
40. Bây giờ, SAU hội thảo, quý vị đánh giá mức độ hiểu biết của mình như thế nào về thông
tin sức khỏe liên quan đến Lời khuyên Tiêu thụ Hải sản Duwamish?
Now, AFTER the workshop, how would you rate your level of knowledge about the health
information related to the Duwamish Seafood Consumption Advisory?
Không / None
Cao / High
Thấp / Low
Trung Bình / Moderate
41. TRƯỚC hội thảo, bạn đánh giá mức độ tin cậy của mình như thế nào khi từ chối hải sản
của ngư dân Duwamish từ gia đình và hàng xóm?
BEFORE the workshop, how would you rate your level of confidence to decline resident
seafood caught in the Duwamish River from your family and neighbors?
Không / None
Thấp / Low
Trung Bình / Moderate
Cao / High
42. Bây giờ, SAU hội thảo, bạn đánh giá mức độ tin cậy của mình như thế nào khi từ chối hải
sản của ngư dân Duwamish từ gia đình và hàng xóm?
Now, AFTER the workshop, how would you rate your level of confidence to decline resident
seafood caught in the Duwamish River from your family and neighbors?
Không / None
Cao / High
Thấp / Low
Trung Bình / Moderate
43. TRƯỚC hội thảo, bạn đánh giá mức độ tự tin của mình như thế nào khi chuẩn bị bữa ăn cá
hồi không da lành mạnh hơn từ sông Duwamish?
BEFORE the workshop, how would you rate your level of confidence to prepare a skinless
healthier salmon meal from the Duwamish River?
Không / None
Thấp / Low
Trung Bình / Moderate
Cao / High
44. Bây giờ, SAU hội thảo, bạn đánh giá mức độ tự tin của mình như thế nào khi chuẩn bị bữa
ăn cá hồi không da lành mạnh hơn từ sông Duwamish?
Now, AFTER the workshop, how would you rate your level of confidence to prepare a skinless
healthier salmon meal from the Duwamish River?
Không / None
Cao / High
Thấp / Low
Trung Bình / Moderate
* 45. Ngày hôm nay
Today's date
Ngày / Date
Date
MM/DD/YYYY
Form Number: 6700-014
| File Type | application/pdf |
| File Modified | 0000-00-00 |
| File Created | 2024-04-08 |