6700-013 Outreach Event Survey

Outreach Event Survey
Outreach Event Survey
Encuesta del Evento de Alcance Comunitario
Câu Hỏi Khảo Sát
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: 6700-013

Outreach Event Survey
OMB Control Number: 2030-0051
2. Which team are you with?

GAL Team

Khmer Team

LARC Team

3. Date

Date / Time

Date

MM/DD/YYYY

4. Event

Vietnamese Team

5. Please select your age group
<18
18-24
25-44
45-64

6. Are you a fisher?
Yes
No

7. Do you know any fishers?
Yes
No

8. Are you a parent or caretaker of young children (6 years or younger)?
Yes
No

9. Are you pregnant or nursing?
Yes
No

10. Which of the following groups are most sensitive to adverse health effects of the
contamination in the Duwamish River? (choose ONE answer)
Pregnant/nursing women & young children
Elderly adults
People who are no longer having children
People who only eat seafood from supermarkets

11. How likely are you to share this information with friends and family?
Extremely Likely
Likely
Neutral
Unlikely
Extremely Unlikely

12. What is one way that you can protect your health from the contaminated seafood in the
Duwamish River? (check all that apply)
Eat only salmon from the Duwamish River
Fish elsewhere
Find healthy options at the grocery store
Stop eating seafood altogether
Don’t eat any fish or seafood caught from local waters (rivers, lakes, and Puget Sound in King County)

13. What is your residential ZIP code?

Form Number: 6700-013

Outreach Event Survey

OMB Control Number: 2030-0051
14.

?

Which team are you with?

GAL Team

Khmer Team

LARC Team

15.
Date

/
Date / Time

Date

MM/DD/YYYY

16.
Event

Vietnamese Team

17.
Please select your age group
<18

18-24

25-44

45-64

>65

18.
Are you a fisher?

?

Yes

No

19.

?

Do you know any fishers?
Yes

No

20.
?
Are you a parent or caretaker of young children (6 years or younger)?
Yes

No

21.

?

Are you pregnant or nursing?

Yes

No

22.
? (

)

Which of the following groups are most sensitive to adverse health effects of the
contamination in the Duwamish River? (choose ONE answer)

Pregnant/nursing women & young children

Elderly adults

People who are no longer having children

People who only eat seafood from supermarkets

23.
?
How likely are you to share this information with friends and family?
Extremely Likely

Likely

Neutral

Unlikely

Extremely Unlikely

24.

? (
)

What is one way that you can protect your health from the contaminated seafood in the
Duwamish River? (check all that apply)
Eat only salmon from the Duwamish River

Fish elsewhere

Find healthy options at the grocery store

Stop eating seafood altogether
(

Puget Sound
)
Don’t eat any fish or seafood caught from local waters (rivers, lakes, and Puget Sound in King County)

25.

ZIP code

What is your residential ZIP code?

?

Form Number: 6700-013

Outreach Event Survey
Encuesta del Evento de Alcance Comunitario
OMB Control Number: 2030-0051
26. ¿Con qué equipo estás?
Which team are you with?

GAL Team

Khmer Team

LARC Team

27. Fecha
Date

Fecha/Hora
Date / Time

Date

MM/DD/YYYY

28. Evento
Event

Vietnamese Team

29. Por favor indique el grupo de edad al que pertenece
Please select your age group
<18
18-24
25-44
45-64

30. ¿Es ud. un/a pescador/a?
Are you a fisher?
Sí
Yes
No

31. ¿Conoce ud. a algún/a pescador/a?
Do you know any fishers?
Sí
Yes
No

32. ¿Es ud. padre/madre o está a cargo de niños (de 6 años o menos)?
Are you a parent or caretaker of young children (6 years or younger)?
Sí
Yes
No

33. ¿Es ud. una mujer embarazada/ en período de lactancia?
Are you pregnant or nursing?
Sí
Yes
No

34. ¿Cuál de los siguientes grupos es más sensible a los efectos adversos para la salud de la
contaminación en el río Duwamish? (escoja UNA respuesta)
Which of the following groups are most sensitive to adverse health effects of the
contamination in the Duwamish River? (choose ONE answer)
Mujeres embarazadas/ en período de lactancia y niños pequeños
Pregnant/nursing women & young children
Adultos mayores
Elderly adults
Personas que no tendrán más hijos
People who are no longer having children
Personas que solo consumen mariscos/pescados de los mercados
People who only eat seafood from supermarkets

35. ¿Qué tan probable es que usted comparta esta información con amigos y familiares?
How likely are you to share this information with friends and family?
Totalmente probable
Extremely Likely
Probable
Likely
Neutro/a
Neutral
Improbable
Unlikely
Totalmente improbable
Extremely Unlikely

36. ¿De qué maneras puede proteger su salud de la contaminación de mariscos en el río
Duwamish? (escoja TODAS que correspondan)
What is one way that you can protect your health from the contaminated seafood in the
Duwamish River? (check all that apply)
Comer solamente salmon del río Duwamish
Eat only salmon from the Duwamish River
Ir a pescar en otro sitio
Fish elsewhere
Buscar opciones saludables en las tiendas
Find healthy options at the grocery store
Dejar de comer mariscos/pescados del todo
Stop eating seafood altogether
NO comer cualquier pescado/mariscos que vengan de aguas locales (ríos, lagos y el Puget Sound en el
condado de King)
Don’t eat any fish or seafood caught from local waters (rivers, lakes, and Puget Sound in King County)

37. ¿Cuál es su código postal residencial?
What is your residential ZIP code?

Form Number: 6700-013

Outreach Event Survey
Câu Hỏi Khảo Sát
OMB Control Number: 2030-0051
38. Bạn làm việc trong nhóm nào?
Which team are you with?

GAL Team

Khmer Team

LARC Team

39. Ngày
Date

Ngày / hồi
Date / Time

Date

MM/DD/YYYY

40. Event

Vietnamese Team

41. Vui lòng đánh dấu nhóm tuổi của bạn
Please select your age group
Dưới 18, <18
18-24
25-44
45-64
Trên 65, >65

42. Bạn có đi đánh bắt hải sản không?
Are you a fisher/Do you harvest seafood?
Có
Yes
Không có
No

43. Bạn có quen ai đi đánh bắt hải sản không? - Do you know anyone who is a fisher / harvests
seafood?
Có
Yes
Không có
No

44. Bạn có phải là phụ huynh hoặc người chăm sóc trẻ em (6 tuổi trở xuống) không? - Are you
a parent or caretaker of young children (6 years or younger)?
Phải
Yes
Không phải
No

45. Bạn có phải là phụ nữ có thai hoặc cho con bú không?
Are you a pregnant or nursing?
Phải
Yes
Không phải
No

46. Sức khỏe của nhóm nào sau đây bị ảnh hưởng nhiều nhất vì ô nhiễm ở sông Duwamish?
(Chọn MỘT câu trả lời)
Which of the following groups are most sensitive to adverse health effects of the
contamination in the Duwamish River? (choose ONE answer)
Phụ nữ mang thai /cho con bú và trẻ em
Pregnant/nursing women & young children
Người cao niên
Elderly adults
Những người không có con hoặc không muốn sinh con nữa
People who are no longer having children
Những người chỉ ăn hải sản từ siêu thị
People who only eat seafood from supermarkets

47. Bạn có mức độ khả năng như thế nào để chia sẻ thông tin này với bạn bè và gia đình?
How likely are you to share this information with friends and family?
Rất có khả năng
Extremely Likely
Có khả năng
Likely
Trung lập
Neutral
Không có khả năng
Unlikely
Rất không có khả năng
Extremely Unlikely

48. Cách nào sau đây có thể bảo vệ sức khỏe của bạn đối với hải sản bị ô nhiễm từ Sông
Duwamish? (Đánh dấu tất cả những đáp án hợp lệ)
What is one way that you can protect your health from the contaminated seafood in the
Duwamish River? (check all that apply)
Chỉ ăn cá hồi từ sông Duwamish
Eat only salmon from the Duwamish River
Đi câu cá ở nơi khác
Fish elsewhere
Tìm các lựa chọn lành mạnh ở chợ
Find healthy options at the grocery store
Ngừng ăn hải sản hoàn toàn
Stop eating seafood altogether
Không ăn cá hoặc hải sản nào được đánh bắt từ vùng biển địa phương (sông, hồ và Puget Sound ở Quận
King)
Don’t eat any fish or seafood caught from local waters (rivers, lakes, and Puget Sound in King County)

49. Mã số vùng của nơi bạn ở (zip code) là gì?
What is your residential ZIP code?

Form Number: 6700-013