EPA TCTAC ICR_Instruments - Feedback Surveys_Specific Events, Activities, Services

Center	Page Number
Center A – Events Survey	2 – 3
Center C – Specific Events/Activities/Services	4 – 5
Center D – Community Champions Program	6 – 7
Center D – Specific Events	8 – 9
Center D – Internship Program	10 – 11
Center D – Specific Support/Technical Assistance	12 – 13
Center E – Exit Survey	14
Center E – 60/120 Day Survey	15 – 16
Center G – Specific Events/Activities/Services	17 – 19
Center H – Specific Events/Services	20 – 21
Center I – Specific Events/Activities/Services	22 – 23
Center J – Specific Events/Services	24 – 25
Center K – Specific Events Services	26 – 27
Center K – Webinar/Training	28 – 30

Feedback Surveys: Specific Events, Activities, or Services

Feedback Survey: Events
Center A 

OMB Control Number = 2035-NEW, Expiration Date = mm/dd/yyyy

This collection of information is approved by OMB under the Paperwork Reduction Act, 44 U.S.C. 3501 et seq. OMB Control Number: 2035-NEW. Responses to this collection of information are voluntary. 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 10 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 Director, Information Engagement Division; 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. 

 

  

Note: Would customize questions 1-4 based on specific training implemented 

 

Organization Name:
The learning aims and/or objectives of the activities were clearly stated.	Strongly agree  Agree  Neutral  Disagree  Strongly disagree
The content presented was accessible and understandable.	Strongly agree  Agree  Neutral  Disagree  Strongly disagree
Did you gain any new knowledge after completing this training session?	Yes  No  If yes, please share any details about the knowledge you have gained
Did you develop any new skills after completing this training session?	Yes  No  If yes, please share any details about the knowledge you have gained
How likely are you to apply the new knowledge and/or skills you have gained to the work you are currently doing?	Not at all likely  Somewhat likely  Very likely
How would you rate the instructor(s) who led this service? Please consider their level of knowledge of the material, the way they presented the material, and how well they responded to participants’ questions.	Excellent  Very good  Satisfactory  Poor  Very poor
How would you rate the resource(s) provided in this training?	Excellent  Very good  Satisfactory  Poor  Very poor
Overall, how satisfied are you with the services received?	Not satisfied  Somewhat satisfied  Very satisfied
Please provide any additional feedback on activities, services, content, or logistics

 

Feedback Survey: Specific Events/Activities/Services 
Center C

OMB Control Number = 2035-NEW, Expiration Date = mm/dd/yyyy

This collection of information is approved by OMB under the Paperwork Reduction Act, 44 U.S.C. 3501 et seq. OMB Control Number: 2035-NEW. Responses to this collection of information are voluntary. 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 2-3 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 Director, Information Engagement Division; 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. 

  

Event Name: Event Date: Event Location:   

{The above 3 fields will be pre-filled when possible}  

 

To what extent do you agree or disagree with each statement below based on your participation in the event, presentation, or service provided (referred to in the survey below as the “activity”)?  

	Strongly disagree	Somewhat disagree	Somewhat agree	Strongly agree
I understood the information and resources that were shared.
I will use the information and resources shared with me going forward.			[if selected, show Q8]	[if selected, show Q8]
I gained new knowledge.
I developed new skills.
The activity matched what I expected based on its description.
The person presenting or leading the activity was knowledgeable and answered questions clearly.
I am overall satisfied with the activity provided.

 

8. [PRE-LOGIC: Only show this question if “somewhat agree” or “strongly agree” was selected for question 2] How do you plan on using what you learned or discussed today in your local community? [text box] 

  

9. How could this activity be improved? [text box]  

  

10. Is there anything else you would like to share about this activity, including suggestions for other events or trainings hosted by the Center C? [text box]  

  

11. What is your zip code? (optional, this helps us better understand how we can support specific areas in EPA Region x)   __________  

Feedback Survey: Community Champions Program 
Center D

OMB Control Number = 2035-NEW, Expiration Date = mm/dd/yyyy

This collection of information is approved by OMB under the Paperwork Reduction Act, 44 U.S.C. 3501 et seq. OMB Control Number: 2035-NEW. Responses to this collection of information are voluntary. 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 20-30 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 Director, Information Engagement Division; 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-participation Survey 

What are you hoping to get out of your participation in the Community Champions program? Please include any discussion topics, training, or other activities that you think would be useful in this program.  

 

Why did you choose to join the Community Champions program?  

 

Which of the following best describes the environmental justice topic area(s) that are most relevant or important in your community?  

• Water quality 

• Air Quality 

• Hazardous Waste 

• Superfund 

• Petrochemical  

• Brownfield 

• Lead 

• Pesticides 

• Chemicals 

• Other, please specify_______________________ 

• Not applicable 

 

 

Post-participation Survey 

 

How will your experience in the Community Champions program support your environmental justice goals and the goals of your organization or community?  

 

What is one action step that you identified and/or implemented because of the Community Champions program to address environmental justice concerns in your community? Please provide a specific example. 

 

In a short paragraph, please describe your biggest success in the Community Champions program. 

 

In a short paragraph, please describe your biggest challenge in the Community Champions program.  

 

How can we improve the Community Champions program in the future?  

 

 

Feedback Survey: Specific Events 
Center D

OMB Control Number = 2035-NEW, Expiration Date = mm/dd/yyyy

This collection of information is approved by OMB under the Paperwork Reduction Act, 44 U.S.C. 3501 et seq. OMB Control Number: 2035-NEW. Responses to this collection of information are voluntary. 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 five to ten 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 Director, Information Engagement Division; 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. 

Which of the following best describes your organization?  

• Advocacy 

• Business 

• College/University/Technical School 

• Community - Neighborhood Network 

• Community Based Organization 

• Education (non-College/University) 

• Government - City or County 

• Government – State 

• Government – Federal 

• Government - Tribal 

• Health Care Provider 

• Health Plan or insurance 

• Media/Public Affairs/Relations 

• Research/Think Tank/Policy Institute 

• Religious organization 

• Trade/Professional/Interest Group 

• Non-Profit Organization 

• Community Member 

• Other: ___________ [Fillable free text field.] 

 

 

Please rate the following statements based on your experience at the service/activity/event. 

	Disagree	Somewhat disagree	Somewhat agree	Agree	Not Applicable
The content in this service/activity/event was presented in a way that was easy to understand.
The content in this service/activity/event was relevant to my work.
I gained knowledge during this event/activity/service that will help me or my organization.
I have identified actions I will take to apply information I learned during this service/activity/event.
Overall, I am satisfied in this event/activity/service.
I am aware of the services offered by Center D.
I know how to access Center D services.
Please provide any details that will help us understand your answers and improve future events/activities/services.

 

What do you consider the most important environmental justice issue faced by your community?  

• Water quality 

• Air Quality 

• Hazardous Waste 

• Superfund 

• Petrochemical  

• Brownfield 

• Lead 

• Pesticides 

• Chemicals 

• Other, please specify_______________________ 

• Not applicable 

• Not sure 

Feedback Survey: Internship Program 
Center D

OMB Control Number = 2035-NEW, Expiration Date = mm/dd/yyyy

This collection of information is approved by OMB under the Paperwork Reduction Act, 44 U.S.C. 3501 et seq. OMB Control Number: 2035-NEW. Responses to this collection of information are voluntary. 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 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 Director, Information Engagement Division; 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. 

 

In a short paragraph, please share how this internship experience will support your environmental justice goals and the goals of the organization or community you worked with. 

 

In a short paragraph, please share what you consider to be your biggest success in your internship placement. 

 

In a short paragraph, please share what you consider to be your biggest challenge in the internship program.  

 

What additional activities or support do you think would be most useful to future interns? 

 

 

Please rate the following statements based on your experience in the internship program.  

	Disagree	Somewhat  disagree	Somewhat agree	Agree	Not applicable
My participation in the internship taught me knowledge or skills I can apply in my future career.
I was able to accomplish my internship goals.
I identified actions I will take to apply what I learned.
My internship experience increased my interest in working in environmental justice.

What type of academic degree program are you currently enrolled in?  

• Certificate or Associate degree 

• Bachelor’s degree 

• Graduate or Doctoral degree 

• Other, please specify: ___________________ 

What degree are you working towards? _____________ 

Which of the following best describes the environmental justice topic area(s)that your internship focused on?  

• Water quality 

• Air Quality 

• Hazardous Waste 

• Superfund 

• Petrochemical  

• Brownfield 

• Lead 

• Pesticides 

• Chemicals 

• Other, please specify_______________________ 

• Not applicable 

Additional comments, suggestions or feedback:  

Feedback Survey: Specific Support / Technical Assistance 
Center D

 

OMB Control Number = 2035-NEW, Expiration Date = mm/dd/yyyy

This collection of information is approved by OMB under the Paperwork Reduction Act, 44 U.S.C. 3501 et seq. OMB Control Number: 2035-NEW. Responses to this collection of information are voluntary. 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 ten 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 Director, Information Engagement Division; 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. 

 

Which type(s) of assistance did you receive from the Center D (mark all that apply): 

• Funding aid (writing, applying for or managing funding) 

• Identifying relevant funding  

• Community Champions 

• Student internship 

• GIS (i.e., computer mapping) 

• Environmental Health/Exposure Science technical assistance 

• Referral to economic development support 

• Referral to social services support 

• Referral to legal services/aid 

• Organizational capacity building 

• Advocacy training/resources 

• Housing repair 

• Research/study design 

• Resource fairs 

• Solar/renewable financing 

• Energy management 

• Policy 

• Other, please specify: _________ 

• Not applicable/ I did not receive assistance from the WEST EJ Center 

 

Which of the following best describes the environmental justice topic area(s) that you received assistance on (mark all that apply):  

• Water quality 

• Air Quality 

• Hazardous Waste 

• Superfund 

• Petrochemical  

• Brownfield 

• Lead 

• Pesticides 

• Chemicals 

• Other, please specify_______________________ 

• Not applicable

Feedback Survey – Exit
Center E

OMB Control Number = 2035-NEW, Expiration Date = mm/dd/yyyy

This collection of information is approved by OMB under the Paperwork Reduction Act, 44 U.S.C. 3501 et seq. OMB Control Number: 2035-NEW. Responses to this collection of information are voluntary. 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 between 5 and 10 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 Director, Information Engagement Division; 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. How satisfied were you with the responsiveness of our team when you reached out for assistance?  

• 1 - Very Dissatisfied • 2 - Dissatisfied • 3 - Neutral • 4 - Satisfied • 5 - Very Satisfied  

 

2. Did our team members effectively address your inquiries or issues? 

• 1 - Very Dissatisfied • 2 - Dissatisfied • 3 - Neutral • 4 - Satisfied • 5 - Very Satisfied  

 

3. How would you rate the professionalism and courtesy of our team during your interaction?  

• 1 - Very Dissatisfied • 2 - Dissatisfied • 3 - Neutral • 4 - Satisfied • 5 - Very Satisfied  

 

4. Were your issues or concerns resolved to your satisfaction by our team? 

 • 1 - Very Dissatisfied • 2 - Dissatisfied • 3 - Neutral • 4 - Satisfied • 5 - Very Satisfied  

 

5. How likely are you to recommend our Center E’s service to others based on your recent experience?  

• 1 - Very Unlikely • 2 - Unlikely • 3 - Neutral • 4 - Likely • 5 - Very Likely  

6. What could we do better (optional)? 

 

7. What is one thing that you would like to elevate that you received (optional)?
   
   

8. Other comments (optional):

Feedback Survey – 60/120 Day
Center E

OMB Control Number = 2035-NEW, Expiration Date = mm/dd/yyyy

This collection of information is approved by OMB under the Paperwork Reduction Act, 44 U.S.C. 3501 et seq. OMB Control Number: 2035-NEW. Responses to this collection of information are voluntary. 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 between 10 and 15 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 Director, Information Engagement Division; 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. 

  

Name of Organization:  

Please answer the following questions based on the results of your inquiry and receiving services from the Center E TCTAC.   

 

 

 

Based on the service(s) you were provided, please answer the following questions and please list the service(s): 

 

1. When did you begin receiving services from Center E?  (__/__/____) 

 

 

2. What services did you receive from Center E? 

 

 

3. What impact did the services received have on your organization and community you serve? 

 

 

4. Did the service(s) improve a counterproductive internal system? Please explain. 

 

 

5. Describe the effects of impact that came about from the services(s) you were provided. 

 

 

6. How did the services expand your capacity to accomplish your organizations mission? 

 

Feedback Survey: Specific Events/Activities/Services
Center G 

OMB Control Number = 2035-NEW, Expiration Date = mm/dd/yyyy

This collection of information is approved by OMB under the Paperwork Reduction Act, 44 U.S.C. 3501 et seq. OMB Control Number: 2035-NEW. Responses to this collection of information are voluntary. 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 ​7 ​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 Director, Information Engagement Division; 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. 
 

​​NOTE: The Center will list the specific activity, event, or service that it is getting feedback on,  
in place of the generic “event/activity/service” label that is currently used in the questions. 

​​ 

​P​re-Event Survey​​ 

​​​​​ 

1. ​​​Consider the topic of this event/activity/service. List the specific technical skills and/or knowledge that you possess prior to participating in this event/activity/service.  
   ​​ 

2. ​​​Consider the key areas to be covered in this event/activity/workshop. What is your self-assessment of your competency in these areas?​​ Of your competency in these areas?​​ 

​​​​​

 

End-Of-Event Survey 

 

1. The aims and/or learning objectives of this event/activity/service were clearly stated.  
   Choose one option: strongly disagree, disagree, agree, strongly agree 
    

2. I understood the content that was presented during this event/activity/service.  
   Choose one option: strongly disagree, disagree, agree, strongly agree 
    

3. Did you gain new knowledge after completing this event/activity/service?  
   Choose one option: yes, no 
   If yes, please provide a short list of what new knowledge you learned. [text box] 
    

4. Did you develop new skills after completing this event/activity/service?  
   Choose one option: yes, no 
   If yes, please provide a short list of what new skills you learned. [text box] 
    

5. How useful do you think this event/activity/service will be to you going forward?  
   Choose one option: not at all useful, a little useful, somewhat useful, very useful 
    

6. ​​In what specific ways do you plan to apply the knowledge or skills you learned during this event in your work?​  
   
   

7. ​​​How relevant do you find the information presented in this event to your current role? 
   ​​ 

8. ​​​Were there any topics covered that you feel are immediately applicable to your work? Yes/No 
   If so, please specify. 
   ​​     ​​ 

9. ​​​Do you anticipate any challenges in implementing the ideas or strategies discussed? Yes/No​​ 
   If yes, what are these challenges? 
   ​​ 

10. ​​​What additional resources or support do you think would help you in applying these concepts effectively? 
    ​​ 

11. ​​​How likely are you to use the information or skills gained from this event in the future? 
    ​​ 

12. ​​​Are there any specific tools, techniques, or knowledge areas from this event that you are particularly excited to use? 
    ​​​​ 

13. How would you rate the ​facilitator​(s) who led this event/activity/service? Please consider their level of knowledge of the material, the way they presented the material, and how well they responded to participants’ questions.  
    Choose one option: excellent, very good, satisfactory, poor, very poor 
    If you would like to explain your answer, please do so here. [text box] 

 

14. How would you rate the resource(s) provided as part of this event/activity/service? Examples of resources include slide-decks, guidance documents, worksheets, templates, etc. 
    Choose one option: excellent, very good, satisfactory, poor, very poor 
    If you would like to explain your answer, please do so here. 
     

15. What worked well in this event/activity/service? Please identify 1 or 2 positive aspects of this session. [text box] 
     

16. What could have gone better in this event/activity/service? Please identify 1 or 2 suggestions for improving this session. [text box] 
     

17. Overall, how would you rate this event/activity/service?  
    Choose one option: excellent, very good, satisfactory, poor, very poor 
    If you would like to explain your answer, please do so here. [text box]​​​ 

​​​​​ 

​​​In cases where Center G is not the facilitator of the session: 
​​ 

18. ​​​Do you consent to having the data from this survey shared with the facilitator of the session? Y/N​​​​​​​​ 

​​​​​ 

​​​Post-Event Survey​​ 

​​​​​ 

1. ​​​Consider the topic of this event/activity/service. List the specific technical skills and/or knowledge that you have developed after participating in this event/activity/service.  
   ​​

 

2. ​​​Consider the key areas that were covered in this event/activity/workshop. What is your self-assessment of your competency in these areas, after having attended? 
   ​​

 

3. ​​​What changes have you implemented in you​​r​​ work or projects as a result of this event/activity/workshop? 
   ​​

 

4. ​​​Please state any long-term benefits or improvements you have seen as a result of attending this event/activity/workshop. 
   ​​

 

5. ​​​Please identify any ongoing challenges or areas in which you believe you need further assistance. ​​​​ 

​​

6. ​​​How accessible did you find the event venue and activities?​​ 

• Very accessible (no issues encountered)​​ 

• ​​​Somewhat accessible (minor issues encountered)​​ 

• ​​​Not very accessible (significant issues encountered)​​ 

• ​​​Not accessible at all (could not access or participate fully)​​ 

• ​​​Not applicable/I do not have mobility challenges​​ 

​​​​​ 

7. ​​​In what ways could we improve accessibility at our events? [text box]​​​​​​ 

Feedback Survey: Specific Events/Services 
Center H

OMB Control Number = 2035-NEW, Expiration Date = mm/dd/yyyy

This collection of information is approved by OMB under the Paperwork Reduction Act, 44 U.S.C. 3501 et seq. OMB Control Number: 2035-NEW. Responses to this collection of information are voluntary. 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 5-15 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 Director, Information Engagement Division; 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. To what extent were the aims and/or learning objectives of this event/activity/service clearly stated? Choose one option: Not at all clearly, a little clearly, somewhat clearly, very clearly 
    

2. To what extent did you understand the content that was presented during this event/activity/service? Choose one option: not at all, a little, somewhat, very much 
    

3. Did you gain new knowledge after completing this event/activity/service?  
   Choose one option: yes, no 
   If yes, please provide a short list of what new knowledge you learned. [text box] 
    

4. Did you develop new skills after completing this event/activity/service?  
   Choose one option: yes, no 
   If yes, please provide a short list of what new skills you learned. [text box] 
    

5. How useful do you think this event/activity/service will be to you going forward?  
   Choose one option: not at all useful, a little useful, somewhat useful, very useful 
    

6. How likely are you to apply the new knowledge and/or skills learned from this event/activity/service?  
   Choose one option: not at all likely, a little likely, somewhat likely, very likely 
    

7. How would you rate the instructor(s) who led this event/activity/service? Please consider their level of knowledge of the material, the way they presented the material, and how well they responded to participants’ questions.  
   Choose one option: excellent, very good, satisfactory, poor, very poor 

If you would like to explain your answer, please do so here. [text box] 

 

8. How would you rate the resource(s) provided as part of this event/activity/service? Examples of resources include slide-decks, guidance documents, worksheets, templates, etc. 
   Choose one option: excellent, very good, satisfactory, poor, very poor 
   If you would like to explain your answer, please do so here. 
    

9. Overall, how would you rate this event/activity/service?  
   Choose one option: excellent, very good, satisfactory, poor, very poor 

If you would like to explain your answer, please do so here. [text box] 

 

10. Which topics did you enjoy learning about the most? Check all that apply. 
    [List to be provided that is specific to the event.] 
     

11. Are there other skills you wish were covered? Check all that apply. 
    [List to be provided that is specific to the event.] 
     

12. Are there other topics you would have liked to learn more about? Check all that apply. 
    [List to be provided that is specific to the event.] 
     

13. If you missed any sessions, what could the training or center provide to help you attend?  
    [text box] 
     

14. What is the biggest highlight from this event/activity/service? [text box] 

 

15. How could the center improve this event/activity/service?  Please list some suggestions for improving the Center’s activities and services. [text box] 

 

16. Is there anything you hoped to learn from the event/activity/service that we did not cover?  
    [text box] 

 

17. If you have any additional comments about the Center’s work, please note them here. [text box] 

Feedback Survey: Specific Events/Activities/Services 
Center I

OMB Control Number = 2035-NEW, Expiration Date = mm/dd/yyyy

This collection of information is approved by OMB under the Paperwork Reduction Act, 44 U.S.C. 3501 et seq. OMB Control Number: 2035-NEW. Responses to this collection of information are voluntary. 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 ​5-10 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 Director, Information Engagement Division; 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. 
 

NOTE: The Center will list the specific activity, event, or service that they are getting feedback on,  
in place of the generic “event/activity/service” label that is currently used in the questions. 

 

1. The aims and/or learning objectives of this event/activity/service were clearly stated.  
   Choose one option: strongly disagree, disagree, agree, strongly agree 
    

2. I understood the content that was presented during this event/activity/service.  
   Choose one option: strongly disagree, disagree, agree, strongly agree 
    

3. Did you gain new knowledge after completing this event/activity/service?  
   Choose one option: yes, no 
   If yes, please provide a short list of what new knowledge you learned. [text box] 
    

4. Did you develop new skills after completing this event/activity/service?  
   Choose one option: yes, no 
   If yes, please provide a short list of what new skills you learned. [text box] 
    

5. How useful do you think this event/activity/service will be to you going forward?  
   Choose one option: not at all useful, a little useful, somewhat useful, very useful 
    

6. How likely are you to apply the new knowledge and/or skills learned from this event/activity/service?  
   Choose one option: not at all likely, a little likely, somewhat likely, very likely 
    

7. Do you plan to take any specific actions based on what you learned in this event/activity/service? Choose one option: yes, no  
   If yes, please list these actions. [text box] 
    

8. How would you rate the instructor(s) who led this event/activity/service? Please consider their level of knowledge of the material, the way they presented the material, and how well they responded to participants’ questions.  
   Choose one option: excellent, very good, satisfactory, poor, very poor 
   If you would like to explain your answer, please do so here. [text box] 

 

9. How would you rate the resource(s) provided as part of this event/activity/service?
   Examples of resources include slide-decks, guidance documents, worksheets, templates, etc. 
   Choose one option: excellent, very good, satisfactory, poor, very poor 
   If you would like to explain your answer, please do so here. 
    

10. What worked well in this event/activity/service?
    Please identify 1 or 2 positive aspects of this session. [text box] 
     

11. What could have gone better in this event/activity/service?
    Please identify 1 or 2 suggestions for improving this session. [text box] 
     

12. Overall, how would you rate this event/activity/service?  
    Choose one option: excellent, very good, satisfactory, poor, very poor 
    If you would like to explain your answer, please do so here. [text box] 
     

13. ​​​Is there anything else you would like to share with us? [open ended]​​ 

Feedback Survey: Specific Events/Services 
Center J

OMB Control Number = 2035-NEW, Expiration Date = mm/dd/yyyy

This collection of information is approved by OMB under the Paperwork Reduction Act, 44 U.S.C. 3501 et seq. OMB Control Number: 2035-NEW. Responses to this collection of information are voluntary. 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 4-8 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 Director, Information Engagement Division; 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. 

 

Thank you for attending an event hosted by Center J. We would appreciate your feedback using the survey below so that we can improve our training and technical assistance for the communities we serve. 

1. To what extent did you understand the content that was presented during this event/activity/service?  
   Choose one option: not at all, a little, somewhat, very much 

 

2. Did you gain new knowledge after completing this event/activity/service?  
   Choose one option: yes, no 
   If you responded yes, please explain what you learned. [text box] 

 

3. I will use what I’ve learned from this training to help me: 

 

Apply for grants or funding opportunities in the future	Choose one option: strongly disagree, disagree, agree, strongly agree
Engage in environmental or energy justice decision-making on key policy or regulatory issues	Choose one option: strongly disagree, disagree, agree, strongly agree
Collaborate with community partners, build coalitions, or strengthen EJ networks	Choose one option: strongly disagree, disagree, agree, strongly agree

 

4. Please rate your level of satisfaction with the following aspects of this training: 

 

Relevance of topic to my needs or interests	Choose one option: very dissatisfied, dissatisfied, satisfied, very satisfied
Format of event	Choose one option: very dissatisfied, dissatisfied, satisfied, very satisfied
Overall quality of event	Choose one option: very dissatisfied, dissatisfied, satisfied, very satisfied

 

5. How would you rate the resource(s) provided as part of this event/activity/service? Examples of resources include slide-decks, links, guidance documents, worksheets, templates, etc. 
   Choose one option: very poor, poor, satisfactory, very good, excellent 

 

6. What other topics would you like to receive training on (related to environmental, energy, or climate justice)? 
   Short answer text box 

 

7. If you have any other feedback or suggestions, please share with us here: 
   Short answer text box 

Feedback Survey Specific Events Services
Center K 

OMB Control Number = 2035-NEW, Expiration Date = mm/dd/yyyy

This collection of information is approved by OMB under the Paperwork Reduction Act, 44 U.S.C. 3501 et seq. OMB Control Number: 2035-NEW. Responses to this collection of information are voluntary. 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 under 7 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 Director, Information Engagement Division; 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. 

 

Thank you for requesting Technical Assistance (TA) from the Center K.    
    
Center K is committed to providing relevant and quality TA. Your feedback helps us evaluate our work and determine areas for improvement. Center K would greatly appreciate your feedback about your experience receiving TA from the Center K, and we hope you will consider responding to this survey.    
    
If you did not receive TA services, please do not complete this survey. 

 

Page Break

 

Q1. Select the type of technical assistance that best applies to the service you received. 

• Navigating federal grant application systems  

• Identifying federal funds with Tribal eligibility  

• Grant writing support  

• GIS mapping services  

• Other  

 

Q2. Did you receive technical assistance from another Center in addition to Center K? If so, which? Select all that apply. 

• No  

• Yes, Center A  

• Yes, Center B  

• Yes, Center C 

• Yes, Center D 

• Yes, Center E 

• Yes, Center F 

• Yes, Center G 

• Yes, Center H 

• Yes, Center I 

• Yes, Center J 

• Yes, Center L 

• Yes, Center M 

• Yes, Center N 

• Yes, Center O 

• Yes, Center P 

 

Q3. Please indicate your level of agreement or disagreement with the following statement.  
"The aims and/or expectations of the technical assistance were clearly stated." 

• Strongly agree  

• Somewhat agree  

• Neither agree nor disagree  

• Somewhat disagree  

• Strongly disagree  

 

Q4. How would you rate the quality of the technical assistance provided by Center K?
Please consider the level of knowledge, communication, and professionalism shared with you. 

• 5 - Very helpful  

• 4 - Somewhat helpful  

• 3 - Neither helpful nor unhelpful  

• 2 - Barely helpful  

• 1 - Not helpful at all  

 

Q5. How would you rate the helpfulness of the resources you received? 

• 5 - Very helpful  

• 4 - Somewhat helpful  

• 3 - Neither helpful nor unhelpful  

• 2 - Barely helpful  

• 1 - Not helpful at all  

 

Q6. Overall, how would you rate your experience receiving technical assistance from Center K? 

• 5 - Very helpful  

• 4 - Somewhat helpful  

• 3 - Neither helpful nor unhelpful  

• 2 - Barely helpful  

• 1 - Not helpful at all  

 

Q7. If you would like to explain your answer to Question 6, please do so here. [text box]

Q8. Do you have any suggestions for improving Center K's delivery of technical assistance? [text box]

Feedback Survey: Webinar/Training 
Center K 

OMB Control Number = 2035-NEW, Expiration Date = mm/dd/yyyy

This collection of information is approved by OMB under the Paperwork Reduction Act, 44 U.S.C. 3501 et seq. OMB Control Number: 2035-NEW. Responses to this collection of information are voluntary. 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 5 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 Director, Information Engagement Division; 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. 
 

Thank you for participating in a webinar or training hosted by the Center K.    
    
Center K is committed to providing relevant and quality webinars and trainings. Your feedback helps us evaluate our work and determine areas for improvement. Center K would greatly appreciate your feedback about your experience participating in a webinar or training from the Center K, and we hope you will consider responding to this survey.    
    
If you did not participate in a webinar or training, please do not complete this survey. 

Q1. Area(s) of Expertise (your role) (Select all that apply) 

• Environmental Technician  

• Environmental Health - Supervisory  

• Environmental Health - Non-Supervisory  

• Community Health Worker or Representative (CHW/CHR)  

• Emergency Management  

• Natural Resources  

• Grant Writing  

• Public Health Professional  

• Sanitation Director  

• Compliance Specialist  

• Safety Specialist  

• Other  
  
  

Q2. Reasons for attending: Why did you attend today’s webinar or training? 

• Required for Job  

• Interesting or Relevant Topic  

• Knowledgeable Presenter(s)  

• Webinar was Free  

• Continuing Education Credits (CEUs)  
  
  

 Q3. How helpful did you find the webinar or training? 

• 5 - Very helpful  

• 4 - Somewhat helpful  

• 3 - Neither helpful nor unhelpful  

• 2 - Barely helpful  

• 1 - Not helpful at all  

Q4. About what percentage of the information was new to you? 

• 100%  

• 75%  

• 50%  

• 25%  

• 0%  

Q5. Please complete the following statement. “I can use this information ______”:

• Immediately  

• In 2-6 months  

• In 7-12 months  

• Never

Q6. Please rate your satisfaction with the content of the webinar or training by indicating your level of agreement or disagreement with each of the following statements. 

	Strongly agree	Agree	Neither agree nor disagree	Disagree	Strongly disagree
The webinar or training delivered the information I expected to receive
Information presented was practical/relevant
The pace of the webinar or training was sufficient for the material covered
Webinar or training provided new knowledge and/or skill applicable to my work

Q7. Please evaluate the presenter or instructor, [insert name of presenter or instructor]. 

Overall:	[text box]
	Strongly agree	Somewhat agree	Neither agree nor disagree	Somewhat disagree	Strongly disagree
Presenter was knowledgeable on the content
Presenter communicated information clearly
Presenter was responsive to audience questions
Presenter was respectful of my cultural beliefs
Presenter displayed good facilitation skills
Presenter provided relevant and high-quality resources

Q8. What was your single biggest takeaway? If applicable, please share how you will use the information from this webinar or training.  [text box]

Q9. What other topics would you be like to see on future webinars or trainings? [text box]

 

Q10. If you have any additional comments, please provide them here. [text box]

 

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